Key Question Chapter Outline Psychology in Your Life

Key Question Psychology in Chapter Outline CORE CONCEPTS Your Life

What Is Therapy? ▼ Paraprofessionals Do Entering Therapy Therapy for psychological Therapy, Too. The Therapeutic Relationship and the disorders takes a variety of Some studies show that the Goals of Therapy forms, but all involve some therapist‘s level of training is not Therapy in Historical and Cultural relationship focused on the main factor in therapeutic Context improving a person’s mental, effectiveness. behavioral, or social functioning.

How Do Psychologists Treat ▼ Where Do Most People Psychological Disorders? Psychologists employ two Get Help? Insight Therapies main forms of treatment: the A lot of therapy is done by friends, Behavior Therapies insight therapies (focused on hairdressers, and bartenders. Cognitive–Behavioral Therapy: developing understanding of A Synthesis the problem) and the behavior Evaluating the Psychological therapies (focused on Therapies changing behavior through conditioning).

How Is the Biomedical ▼ What Sort of Therapy Would Approach Used to Treat Biomedical therapies seek to You Recommend? Psychological Disorders? treat psychological disorders There is a wide range of therapeutic by changing the brain’s Drug Therapy/Psychopharmacology possibilities to discuss with a friend chemistry with drugs, its Other Medical Therapies for Mental who asks for your recommendation. circuitry with surgery, or its Disorder patterns of activity with pulses Hospitalization and the Alternatives of electricity or powerful magnetic ﬁelds.

Therapies: The State of the Art

USING PSYCHOLOGY TO LEARN PSYCHOLOGY: How Is Education Like Therapy? Chapter Therapies for 1313 Psychological Disorders

AURA, A PETITE WOMAN in her 40s with a Lcontagious smile, speaks intently about her profession as a psychotherapist. “Yes,” she says, “Once your therapeutic practice is established, you might enjoy greater flexibil- ity, autonomy, and meaningfulness than in many other careers. But no, it’s not easy work, and it demands both an intellectual and an emotional investment. Moreover,” Laura protests, dispelling a common myth about therapy, “A therapist is not a ‘paid friend’! A therapist is a trained professional who knows the art of establishing a helping relationship and knows how to apply the knowledge of psychology to an individual struggling with problems and choices.” Laura’s orientation is in humanistic therapy, an approach aimed at helping clients see themselves clearly. Humanistic therapies are designed for individuals who seek to be more adaptive, healthy, and productive in their lives. “Early in the therapeutic relationship, my role might be somewhat parental,” Laura explains. “Perhaps my client never had the opportunity to grow up with real support. As a child, this client may have created a way to function that worked for her. But now, she needs to be an adult—not a child—and she gets pushed back into those old ways of reacting. It becomes self- sabotaging. The client feels stuck.” Laura sits quietly for a few moments, then goes 523 on. “Since I’ve been there myself, I recognize it. When the client finally trusts me enough, I point these issues out to her, and she can begin to take charge of her life in a healthier way.” Today, practicing psychotherapists may hold any of dozens of degrees and certifi- cations, choosing from scores of therapeutic techniques. For all that training, however, Laura insists that working as a therapist is not purely a science. “Therapy is also an art,” asserts Laura, “It’s experiential. We may know the skills required to be an effective therapist, like listening well. And we know the central issues, like trust between therapist and client. But these aren’t enough to make someone a good therapist. You also need personal experience and insight. You need to be able to sense what your client cannot communicate. And there’s no science for that—it’s intuitive.” But there’s still more to having a psychotherapy practice, Laura points out: “It’s not only challenging cases that are difficult! Sometimes it’s the hassles of dealing with health insurance that get to you.” Laura grins. “But when the therapeutic relationship is real, and our work together progresses, it’s very satisfying—even, sometimes, fun! Once we finally ‘get it,’ my client and I can laugh together. “I do love it. I love the intensity of it,” Laura concludes. “As a therapist, I am there for my clients—with my clients. I see them clearly. They come to me with the gift of their trust. It’s awe-inspiring. And they wouldn’t come if they didn’t have the strength and the love to keep going and keep growing.”

■ Therapy A general term for any treatment process; in psychology and psychiatry, therapy refers to a variety of psychological and biomedical techniques As Laura makes clear, therapists work at the interface between the science and aimed at dealing with mental disorders or art of helping. Her approach to therapy, as you will see in this chapter, is just coping with problems of living. one of many ways to be a therapist. Yet, despite the diversity of approaches that Laura and her colleagues bring to their work, the over- whelming majority of people who enter therapy receive significant help. Not everyone becomes a success case, of course. Some people wait too long, until their problems become intractable. Some do not end up with the right sort of therapy for their problems. And, unfortunately, many people who could benefit from therapy do not have access to it because of financial constraints. Still, the development of a wide range of effective therapies is one of the success stories in modern psychology. In this next-to-last chapter of our journey together through psychology, we begin an overview of therapy by considering what therapy is, who seeks it, what sorts of problems they bring to it, and who administers it. Here we will also see how therapeutic practices have been influenced by history and culture. In the second section of the chapter, we will consider the major types of psychological treatments currently used and how well they work. Then, in the final section, we will look at medical treatments for mental disorders, including drug therapy, psychosurgery, and “shock treatment.” There we will also compare hospital treatment for mental disorder with community-based treatment. As you read through this chapter, we hope you will weigh the advantages and disadvantages of each therapy. Keep in mind, too, that you may sometime be asked by a friend or rel- ative to use what you have learned here to recommend an ● Many people could benefit from some form of therapy. Most appropriate therapy. It’s even possible that you may sometime people who enter therapy receive significant help. need to select a therapist for yourself.

524 CHAPTER 13 ❚ THERAPIES FOR PSYCHOLOGICAL DISORDERS WHAT IS THERAPY? When you think of “therapy,” chances are that a stereotype pops into mind, absorbed from countless cartoons and movies: a “neurotic” patient lying on the analyst’s couch, with a bearded therapist sitting at the patient’s head, scrib- bling notes and making interpretations. In fact, this is a scene from classic Freudian psychoanalysis, which is a rarity today, although it dominated the ﬁrst half of the 20th century. The reality of modern therapy differs from the old stereotype on several counts. First, most therapists don’t have their patients (or clients) lie on a couch. Second, people now seek therapeutic help for a wide range of problems besides the serious DSM-IV disorders: People also go to counselors or therapists for help in making difficult choices, dealing with academic problems, and coping with losses or unhappy relationships. And here’s a third way in which the stereotype of therapy is false: Some forms of therapy now involve as much action as they do talk and interpretation—as you will see shortly.

At ﬁrst, the therapeutic menu may appear to offer a bewildering list of choices, involving talk and interpretation, behavior modiﬁcation, drugs, and, in some cases, even “shock treatment” or brain surgery. No matter what form therapy takes, however, there is one constant, as our Core Concept suggests:

Therapy for psychological disorders takes a variety of forms, but all involve some relationship focused on improving a person’s mental, behavioral, or social functioning.

In this chapter, as we examine a sample from the therapeutic universe, we will see that each form of therapy is based on different assumptions about mental disorder. Yet all involve relationships designed to change a person’s functioning in some way. Let’s begin our exploration of therapy by looking at the variety of people who enter treatment and the problems they bring with them to the therapeutic relationship.

WHAT IS THERAPY? 525 Entering Therapy Why would you go into therapy? Why would anyone? Most often, people enter therapy when they have a problem that they are unable to resolve by themselves. They may seek therapy on their own initiative, or they may be advised to do so by family, friends, a physician, or a coworker.

Cathy by Cathy Guisewite/Universal Press Syndicate

Obviously, you don’t have to be “crazy” to seek therapy. If you do enter therapy, however, you may be called either a patient or a client. Practitioners CONNECTION CHAPTER 12 who take a biological or medical approach to treatment commonly use the term The medical model assumes that mental patient. On the other hand, client is often used by professionals who think of disorders are similar to physical diseases. psychological disorders not as mental illnesses but as problems in living (Rogers, 1951; Szasz, 1961). Access to therapy can be affected by a variety of factors. As we have noted, therapy is far easier to obtain if you have money or adequate health insurance. For the poor, especially poor ethnic minorities, economic obstacles block access to professional mental health care (Bower, 1998d; Nemecek, 1999). Another problem can be lack of qualiﬁed therapists. In many communities, it is still much easier to get help for physical health problems than for psychological problems. Even the nature of a person’s psychological problems can interfere with getting help. An individual with agoraphobia, for example, ﬁnds it hard, even impossible, to leave home to seek therapy. Similarly, paranoid persons may not seek help because they don’t trust mental health professionals. Obviously, many problems remain to be solved before all those who need therapy can get it.

The Therapeutic Relationship and the Goals of Therapy Sometimes you only need to talk out a problem with a sympathetic friend or family member, perhaps to “hear yourself think” or to receive reassurance that you are still worthwhile or likeable. But friends and family have needs and agendas of their own that may interfere with helping you. In fact, they may sometimes be part of the problem. For whatever reason, when the people you are close to cannot offer the help and support you need, it may be appropriate to seek the help of a professionally trained therapist. You might also want professional help if you wish to keep your problems and concerns conﬁdential. Moreover, professional therapists have expertise in identifying mental disorders and in using therapeutic techniques that a friend would probably not know about and certainly would not have the skills to employ. In all these ways, a professional relationship with a therapist differs from friendship or kinship. What Are the Components of Therapy? In nearly all forms of therapy there is some sort of relationship between the therapist and the patient/client seeking

526 CHAPTER 13 ❚ THERAPIES FOR PSYCHOLOGICAL DISORDERS assistance—as our Core Concept indicates. (There are computer-therapy programs, where the idea of a “relationship” is stretching the point.) Trust is one of the essential ingredients of a good therapeutic relationship. You and your therapist must be able to work together as allies, on the same side and toward the same goals, joining forces to cope with and solve the problems that have brought you to therapy (Horvath & Luborsky, 1993). It also helps if you believe that therapy will be effective for your problem. In addition to the relationship between therapist and client, depending on the specific approach used, the therapeutic process typically involves some or all of the following processes: 1. Identifying the problem: This may mean merely agreeing on a simple descrip- tion of circumstances or feelings to be changed, or, in the case of a DSM-IV disorder, this step may call for a formal diagnosis about what is wrong. 2. Identifying the cause of the problem or the conditions that maintain the problem: In some forms of therapy, this involves searching for the source of the patient’s or client’s discomfort. Alternatively, other forms of therapy emphasize the present causes—that is, the conditions that are keeping the problem alive. 3. Deciding on and carrying out some form of treatment: This involves selecting a specific type of therapy designed to minimize or eliminate the troublesome symptoms. Who Does Therapy? Although more people seek out therapy now than in the past, people usually turn to trained mental health professionals only when their psychological problems become severe or persist for extended periods. When they do, those seeking therapy usually choose one of seven main types of professional helpers: counseling psychologists, clinical psychologists, psychiatrists, psychoanalysts, psychiatric nurse practitioners, clinical (psychiatric) social workers, or pastoral counselors. The differences among these specialties are detailed in Table 13.1. As you examine that table, note that each specialty has its area of expertise. For example, the only therapists who are widely licensed to prescribe drugs are psychiatrists, psychoanalysts (with medical degrees), and psychiatric nurse practitioners. Currently, through their professional organizations, clinical psychologists are seeking to obtain prescription privileges (Sternberg, 2003). Already, a few military psychologists have been trained, in a highly acclaimed program, to prescribe drugs (Dittmann, 2004; Newman et al., 2000; Rabasca, 1999). And in 2002, New Mexico became the first state to grant prescription privileges to psychologists who have completed a rigorous training program, including 850 hours of course work and supervised internship (Dittmann, 2003). Similar leg- islation has been introduced in a dozen other states. Nevertheless, prescription privileges for psychologists remains a highly political issue, hotly contested by the medical profession (Clay, 1998; Hayes & Heiby, 1996; Sleek, 1996).

Therapy in Historical and Cultural Context How you deal with mental disorder depends on how you think about mental disorder. If you believe, for example, that mental problems are diseases, you will treat them differently than another person who believes they indicate a ﬂaw in one’s character or a sign of inﬂuence by evil spirits. Likewise, the way society treats people with mental disorders has always depended on its pre- vailing beliefs. History of Therapy As we saw in the previous chapter, people in medieval Europe often interpreted mental disorder as the work of devils and demons.

WHAT IS THERAPY? 527 TABLE 13.1 Types of Mental Health Care Professionals

Professional title Specialty and common work settings Credentials and qualifications Counseling psychologist Provides help in dealing with the common problems of Depends on the state: typically at least a master’s in normal living, such as relationship problems, child rearing, counseling, but more commonly a PhD (Doctor of occupational choice, and school problems. Typically Philosophy), EdD (Doctor of Education), or PsyD counselors work in schools, clinics, or other institutions. (Doctor of Psychology) Clinical psychologist Trained primarily to work with those who have more Usually required to hold PhD or PsyD; often an severe disorders, but may also work with clients having internship and state certification required. less severe problems. Usually in private practice or employed by mental health agencies or by hospitals. Not typically licensed to prescribe drugs. Psychiatrist A specialty of medicine; deals with severe mental MD (Doctor of Medicine); may be required to be problems—most often by prescribing drugs. May be certified by medical specialty board. in private practice or employed by clinics or mental hospitals. Psychoanalyst Practitioners of Freudian therapy. Usually in private practice. MD (some practitioners have doctorates in psychology, but most are psychiatrists who have taken additional training in psychoanalysis). Psychiatric nurse A nursing specialty; licensed to prescribe drugs for mental Requires RN (Registered Nurse) credential, plus special practitioner disorders. May work in private practice or in clinics and training in treating mental disorders and prescribing hospitals. drugs. Clinical or psychiatric Social workers with a specialty in dealing with mental MSW (Master of Social Work) social worker disorders, especially from the viewpoint of the social and environmental context of the problem. Pastoral counselor A member of a religious order or ministry who specializes Varies in treatment of psychological disorders. Combines spiritual guidance with practical counseling.

In that context, then, the job of the “therapist” was to perform an exorcism or to “beat the devil” out of the disordered person—to make the body an inhos- pitable place for a spirit or demon. In more recent times, however, reformers have urged that the mentally ill be placed in institutions called asylums, where they could be shielded from the stresses of the world—and from the brutal “therapies” that had been all too customary. Unfortunately, the ideal of the insane asylums was not often realized. One of the most infamous of the asylums was also one of the ﬁrst: Bethle- hem Hospital in London, where for a few pence on the weekend sightseers could go to observe the inmates, who often put on a wild and noisy “show” for the curious audience. As a result, “Bedlam,” the shortened term Londoners used for “Bethlehem,” became a word used to describe any noisy, chaotic place. In most asylums, inmates received, at best, only custodial care; at worst they were neglected or put in cruel restraints, such as cages and straightjackets. Some even continued to receive beatings, cold showers, and other forms of abuse. It’s not hard to guess that such treatment rarely produced improvement in people suffering from psychological disorders. Modern Approaches to Therapy Modern mental health professionals have abandoned the old demon model and frankly abusive treatments in favor of therapies based on psychological and biological theories of mind and behavior. Yet, as we will see, even modern professionals disagree on the exact causes and the most appropriate treatments—a state of the art that gives us a wide variety of therapies from which to choose. To help you get an overview of this cluttered therapeutic landscape, here is a preview of things to come.

528 CHAPTER 13 ❚ THERAPIES FOR PSYCHOLOGICAL DISORDERS The psychological therapies are often collectively called simply psychother- ■ Psychological therapies Therapies apy.1 They focus on changing disordered thoughts, feelings, and behavior using based on psychological principles (rather than psychological techniques (rather than biomedical interventions). And they come on the biomedical approach); often called “psychotherapy.” in two main forms. Insight therapy focuses on helping people understand their ■ Biomedical therapies Treatments problems and change their thoughts, motives, or feelings. Behavior therapy that focus on altering the brain, especially with focuses primarily on behavior change. drugs, psychosurgery, or electroconvulsive In contrast with psychotherapy, the biomedical therapies focus on treating therapy. mental problems by changing the underlying biology of the brain. To do so, a physician or nurse practitioner can employ a variety of drugs, including antidepressants, tranquilizers, and stimulants. Occasionally the brain may be treated directly with electromagnetic stimulation or even surgery. Disorder and Therapy in a Cultural Context Ways of thinking about and treating mental disorder vary widely across cultures (Matsumoto, 1996). Indi- vidualistic Western (European and North American) views and practices generally regard psychological disorders to be the result of disease processes, abnormal genetics, distorted thinking, unhealthy environments, or stressors. But collectivist cultures often have quite different perspectives (Triandis, 1990; Zaman, 1992). Asian societies may think of mental disorder as a disconnect between the person and the group. Likewise, many Africans believe that mental disorder results when an individual becomes estranged from nature and from the community, including the community of ancestral spirits (Nobles, 1976; Sow, 1977). In such cultures, treating mentally disturbed individuals by removing them from society is unthinkable. Instead, healing takes place in a social context, emphasizing a distressed person’s beliefs, family, work, and life environment. An African use of group support in therapy has

● In this painting from the 1730s, we see the chaos of a cell in the London hospital St. Mary of Bethlehem. Here the upper classes have paid to see the horrors, the ﬁddler who entertains, and the mental patients chained, tortured, and dehuman- ized. The chaos of Bethlehem eventually became synonymous with the corruption of its name—Bedlam.

1No sharp distinction exists between counseling and psychotherapy. In general, however, counseling is a shorter process, more likely to be focused on a speciﬁc problem, while psychotherapy characteristically involves a longer-term and wider-ranging exploration of issues.

WHAT IS THERAPY? 529 developed into a procedure called “network therapy,” where a patient’s entire network of relatives, coworkers, and friends becomes involved in the treatment (Lambo, 1978). In many places around the world, the treatments of both mental and physical problems is also bound up with religion and the supernatural—much as in medieval Europe, although their treatments are not usually so harsh. Certain persons—priests, ministers, shamans, sorcerers, and witches—are assumed to have special mystical powers to help distressed fellow beings. Their methods involve ceremonies and rituals that bring emotional intensity and meaning into the healing process. Combined with the use of symbols, they connect the individual sufferer, the shaman, and the society to supernatural forces to be won over in the battle against madness (Devereux, 1981; Wallace, 1959).

PSYCHOLOGY IN YOUR LIFE: PARAPROFESSIONALS ● In many cultures, treatments for mental DO THERAPY, TOO and physical disorders are closely allied with religious beliefs. Here, a Native American Does the best therapy always require a highly trained (and expensive) pro- healer concentrates on spiritual forces that fessional? Or can paraprofessionals—who may have received on-the-job train- are presumed to have a role in the woman’s ing in place of graduate training and certification—be effective therapists? If discomfort. you are seeking treatment, these questions are important because hospitals, clinics, and agencies are increasingly turning to paraprofessionals as a cost- cutting measure: Those who lack full professional credentials can be hired at a fraction of the cost of those with professional degrees. They are often called “aides” or “counselors” (although many counselors do have professional credentials). Surprisingly, a review of the literature has found no substantial differences in the effectiveness of the two groups across a wide spectrum of psychological problems (Christensen & Jacobson, 1994). This is good news in the sense that the need for mental health services is far greater than the number of professional therapists can possibly fill. And, because paraprofessional therapists can be effective, highly trained professionals may be freed for other roles, including prevention and community education programs, assessment of patients, training and supervision of paraprofessionals, and research. The reader should be cautioned about overinterpreting this finding, however. Pro- fessionals and paraprofessionals have been found to be equivalent only in the realm of the insight therapies, which we will discuss in a moment (Zilbergeld, 1986). Such differences have not yet been demonstrated in the areas of behav- ● More and more therapy is being done by ior therapies, which require extensive knowledge of operant and classical con- paraprofessionals. ditioning and of social-learning theory.

CHECK YOUR UNDERSTANDING

1. RECALL: People in collectivist cultures are likely to view mental 2. RECALL: A therapist, but not necessarily a friend, can be relied on to disorder as a symptom of something wrong in a. maintain conﬁdentiality. a. the unconscious mind. b. give you good advice. b. a person’s behavior, rather than in the mind. c. offer sympathy when you are feeling depressed. c. a person’s relationship with family or community. d. be available when needed. d. a person’s character. e. all of the above. e. a person’s attitude.

530 CHAPTER 13 ❚ THERAPIES FOR PSYCHOLOGICAL DISORDERS 3. APPLICATION: Which of the following therapists would be most a. All may be legally administered only by licensed, trained likely to treat an unwanted response, such as nail biting, as merely a professionals. bad habit, rather than as a symptom of an underlying disorder? b. All make use of insight into a patient’s problems. a. a psychoanalyst d. a group therapist. c. All involve the aim of altering the mind, behavior, or social b. a psychiatrist e. a behavioral therapist relationships. c. an insight therapist d. All focus on discovering the underlying cause of the patient’s problem, which is often hidden in the unconscious mind. 4. In what respect UNDERSTANDING THE CORE CONCEPT: e. All involve a change in an individual’s behavior.

are all therapies alike?

c e a c 4. 4. 3. 2. 1. ANSWERS:

HOW DO PSYCHOLOGISTS TREAT PSYCHOLOGICAL DISORDERS? Jim is depressed about his grades, his lack of direction in school, his relationship with Sheila... about everything. Sheila helps him make an appointment at the psychology department’s depression clinic. The sort of therapy Jim will receive depends on whether the therapist prefers insight therapy or behavior therapy. Insight therapy, as you will see, helps the individual gain an understanding of the problem. Various forms of insight therapy are based on the theories of personality we discussed in Chapter 10 and on the cognitive theories of perception, learning, and memory we discussed in Chapters 4, 6, and 7. The behavior therapies, on the other hand, put less emphasis on understanding and insight, while focusing more directly on changing behavior. They draw mainly on the work of Pavlov (classical conditioning) and Skinner (operant conditioning). Our Core Concept puts these ideas together in fewer words:

Psychologists employ two main forms of treatment: the insight therapies (focused on developing understanding of the problem) and the behavior therapies (focused on changing behavior through conditioning).

The insight therapies, we shall see, were the ﬁrst truly psychological treatments developed, and for a long time they were the only psychological therapies available. In recent years they have been joined by the behavior therapies, which are now among the most effective tools we have. But it is with the insight therapies that we begin.

Insight Therapies The insight therapies attempt to change people on the inside—changing the way they think and feel. Sometimes called talk therapies, these methods share the assumption that distressed persons need to develop an understanding of the disordered thoughts, emotions, and motives that underlie their mental difficulties. The insight therapies come in dozens of different “brands,” but all take a clinical perspective, using various techniques for revealing and changing a patient’s disturbed mental processes through discussion and interpretation. Some, such as Freudian psychoanalysis, assume that problems lie hidden deep ■ Insight therapies Psychotherapies in the unconscious, so they employ elaborate and time-consuming techniques in which the therapist helps patients/clients to draw them out. Others, such as Carl Rogers’s nondirective therapy, minimize understand (gain insight into) their problems. ■ Talk therapies Psychotherapies that the importance of the unconscious and look for problems in the ways people focus on communicating and verbalizing think and interact with each other. Most modern insight therapies require much emotions and motives to understand their less time—usually weeks or months—than the years demanded by traditional problems.

HOW DO PSYCHOLOGISTS TREAT PSYCHOLOGICAL DISORDERS? 531 Freudian psychoanalysis. We have space here to examine only a sam- Insight Therapies pling of the most influential ones, beginning with the legendary methods developed by Sigmund Freud. (See the chart in the margin.) ● Freudian psychoanalysis ● Neo-Freudian therapies Freudian Psychoanalysis In the classic Freudian view, psychological problems arise from tension created in the unconscious mind by ● Humanistic therapies forbidden impulses and threatening memories. Therefore, Freudian ● Cognitive therapies therapy, known as psychoanalysis, probes the unconscious in an ● Group therapies attempt to bring these issues into the “light of day”—that is, into consciousness, where they can be rendered harmless. The major goal of psychoanalysis, then, is to reveal and interpret the contents of the unconscious mind. To get at unconscious material, Freud needed ways to get around the defenses the ego has erected to protect itself. One ingenious method called for free association, by which the patient would relax and talk about whatever came to mind, while the therapist would listen, ever alert for veiled references to unconscious needs and conflicts. Another method involved dream interpre- CONNECTION CHAPTER 12 tation, which you will recall from Chapter 3. The ego defense mechanisms include With these and other techniques, the psychoanalyst gradually developed a repression, regression, projection, denial, clinical picture of the problem and proceeded to help the patient understand rationalization, reaction formation, the unconscious causes for symptoms. To give you the flavor of this process, displacement, and sublimation. we offer Freud’s interpretation of a fascinating case involving a 19-year-old girl diagnosed with “obsessional neurosis” (now listed in the DSM-IV as obsessive–compulsive disorder). Please bear in mind that Freud’s ideas no longer rep- resent the mainstream of either psychology or psychiatry. But they remain important because many of Freud’s techniques have carried over into newer forms of therapy. They are also important because many of Freud’s concepts, such as ego, repression, the unconscious, identification, and Oedipus complex, have become part of our everyday vocabulary. The following case, then—in which you may find Freud’s interpretations shocking—will give you a sense of the way psychotherapy began about a century ago. With these cautions in mind, then, let’s meet Freud’s patient. When the girl entered treatment, she was causing her parents distress with a strange bedtime ritual that she performed each night. As part of this ritual, she first stopped the large clock in her room and removed other smaller clocks, including her wrist watch. Then she placed all vases and flower pots together on her writ- ing table, so—in her “neurotic” way of thinking—they could not fall and break during the night. Next, she ensured that the door of her room would remain half open by placing various objects in the doorway. After these precautions, she turned her attention to the bed, where she made certain that the bolster did not touch the headboard and that a pillow lay diagonally in the center of the bolster. Then she shook the eiderdown in the quilt until all the feathers sank to the foot-end, after which she meticulously redistributed them evenly again. And finally, she would crawl in bed and attempt to sleep with her head pre- cisely in the center of the diagonal pillow. The ritual did not proceed smoothly, however. She would do and then redo first one and then another aspect of the ritual, anxious that she had not performed everything properly—although she acknowledged to Freud that all aspects of her nightly precautions were irrational. The result was that it took the girl about two hours to get everything ready for bed each night. As we mentioned above, establishing a relationship with the patient is essential to psychoanalysis, and through this, Freud made some dramatic claims about her behavior. Not the least of which centered around unfulfilled sexual desires. ■ Psychoanalysis The form of psychodynamic therapy developed by Sigmund Freud. These revelations came about through free-association, having the patient say The goal of psychoanalysis is to release con- the first that comes to mind, and by looking at resistances, which are topics flicts and memories from the unconscious. and ideas that the patient avoids talking about in therapeutic sessions.

532 CHAPTER 13 ❚ THERAPIES FOR PSYCHOLOGICAL DISORDERS ● Sigmund Freud’s study, including the famous couch (right), is housed in London’s Freud Museum. The 82-year-old Freud ﬂed to London in 1938 upon the Nazi occupation of Austria and died there the following year.

In the final stage of psychoanalysis, patients learn how the relationship they have established with the therapist reflects the unresolved problems they had with their parents. This projection of parental attributes onto the therapist is called transference, and the final phase of therapy is known as the analysis of transference. According to psychoanalytic theory, patients will recover when they are finally released from the repressive mental restraints established in the relationship with their parents during early childhood (Munroe, 1955). Neo-Freudian Psychodynamic Therapies Please pardon us for doing a bit of analysis on Freud: He had a flair for the dramatic, and he also possessed a powerful, charismatic personality—or, as he himself might have said, a strong ego. Accordingly, Freud encouraged his disciples to debate the principles of psychoanalysis, but he would tolerate no fundamental changes in his doctrines. This inevitably led to conflicts with some of his equally strong-willed follow- ers, such as Alfred Adler, Carl Jung, and Karen Horney, who eventually broke with Freud to establish their own schools of therapy. In general the neo-Freudian renegades retained many of Freud’s basic ideas and techniques, while adding some and modifying others. In the true psychodynamic tradition, the neo-Freudian psychodynamic therapies have retained Freud’s emphasis on motivation. Most now have abandoned the psychoanalyst’s couch and treat patients face-to-face. Most also see patients once a week for a few months, rather than several times a week for several years, as in classical psychoanalysis. So how do the neo-Freudian therapists get the job done in a shorter time? Most have shifted the emphasis from the unconscious to conscious motiva- ■ Analysis of transference tion—so they don’t spend so much time probing for hidden conflicts and The Freudian technique of analyzing and repressed memories. Most have also made a break with Freud on one or more interpreting the patient’s relationship with the of the following points: therapist, based on the assumption that this ❚ relationship mirrors unresolved conflicts in The significance of the self or ego (rather than the id) the patient’s past. ❚ The influence of life experiences occurring after childhood (as opposed to ■ Neo-Freudian psychodynamic Freud’s emphasis on early-childhood experience) therapies Therapies for mental disorder that were developed by psychodynamic ❚ The role of social needs and interpersonal relationships (rather than sexual theorists who embraced some of Freud’s and aggressive desires) ideas but disagreed with others.

HOW DO PSYCHOLOGISTS TREAT PSYCHOLOGICAL DISORDERS? 533 And, as we saw in Chapter 11, each constructed a theory of disorder and therapy that had different emphases. We do not have space here to go into these approaches in greater detail, but let’s briefly consider how a neo-Freudian therapist might have approached the case of the obsessive girl that Freud described. Most likely a modern psychodynamic therapist would focus on the current relationship between the girl and her parents, perhaps on whether she has feelings of inadequacy for which she is compensating by becoming the center of her parents’ attention for two hours each night. And, instead of working so intensively with the girl, the therapist might well work with the parents on changing the way they deal with the problem. Humanistic Therapies The primary symptoms for which college students seek therapy include low self-esteem, feelings of alienation, failure to achieve all they feel they should, difficult relationships, and general dissatisfaction with their lives. These problems in everyday existence are commonly called exis- tential crises. This term underscores the idea that many problems deal with questions about the meaning and purpose of one’s existence. The humanistic psychologists have developed therapies aimed specifically at these problems—and this is the approach pre- ferred by Laura, the therapist we met at the beginning of the chapter. Humanistic therapists believe that people are generally motivated by healthy needs for growth and psychological well- being. Thus, they dispute Freud’s assumption of a personality divided into conflicting parts, dominated by a selfish id, and driven by hedonistic instincts and repressed conflicts. Rather, the humanists emphasize the concept of a whole person engaged in a continual process of change. Humanistic therapists also assume that mental disorder occurs only when conditions interfere with normal development and produce low self-esteem. Humanistic therapies, therefore, attempt to help ● Humanistic therapist Carl Rogers (right clients confront their problems by recognizing their own free- center) facilitates a therapy group. dom, enhancing their self-esteem, and realizing their fullest potential (see Schneider & May, 1995). A humanistic therapist (if there had been one around a century ago) would probably have worked with Freud’s patient to explore her self-concept and her feelings about her parents. There would have been no attempt at interpreting the girl’s symptoms. Among the most influential of the humanistic therapists, Carl Rogers (1951, 1977) developed a method called client-centered therapy, which assumes that all people have the need to self-actualize—that is, to realize their potential. But healthy development can be hindered by a conflict between one’s desire for a positive self-image and criticism by self and others. This conflict creates anxi- ■ Humanistic therapies Treatment ety and unhappiness. The task of Rogerian therapy, then, is to create a nur- techniques based on the assumption that turing environment in which clients can work through their conflicts to achieve people have a tendency for positive growth self-enhancement and self-actualization. and self-actualization, which may be blocked by an unhealthy environment that can include One of the main techniques used by Rogerian therapists involves reflection negative self-evaluation and criticism from of feeling (also called reflective listening) to help clients understand their emo- others. tions. With this technique therapists paraphrase their clients’ words, attempt- ■ Client-centered therapy ing to capture the emotional tone expressed and acting as a sort of psycho- A humanistic approach to treatment developed logical “mirror” in which clients can see themselves. Notice how the Rogerian by Carl Rogers, emphasizing an individual’s tendency for healthy psychological growth therapist uses reflection of feeling in the following excerpt from a therapy ses- through self-actualization. sion with a young woman (Rogers, 1951, p. 152): ■ Reflection of feeling Carl Rogers’s technique of paraphrasing the clients’ words, CLIENT: It probably goes all the way back into my childhood.... My attempting to capture the emotional tone mother told me that I was the pet of my father. Although I expressed. never realized it—I mean, they never treated me as a pet at all.

534 CHAPTER 13 ❚ THERAPIES FOR PSYCHOLOGICAL DISORDERS And other people always seemed to think I was sort of a privi- leged one in the family.... And as far as I can see looking back on it now, it’s just that the family let the other kids get away with more than they usually did me. And it seems for some reason to have held me to a more rigid standard than they did the other children. THERAPIST: You’re not so sure you were a pet in any sense, but more that the family situation seemed to hold you to pretty high standards. CLIENT: M-hm. That’s just what has occurred to me; and that the other people could sorta make mistakes, or do things as children that were naughty... but Alice wasn’t supposed to do those things. THERAPIST: M-hm. With somebody else it would be just—oh, be a little naughtiness; but as far as you were concerned, it shouldn’t be done. CLIENT: That’s really the idea I’ve had. I think the whole business of my standards... is one that I need to think about rather carefully, since I’ve been doubting for a long time whether I even have any sincere ones. THERAPIST: M-hm. Not sure whether you really have any deep values which you are sure of. CLIENT: M-hm. M-hm. In stark contrast with psychoanalysis, the Rogerian therapist assumes that people have basically healthy motives. These motives, however, can be stiﬂed or distorted by social pressures and low self-esteem. The therapist’s task is mainly to remove barriers that limit the expression of this natural positive tendency and help the client clarify and accept his or her own feelings. This is accomplished within an atmosphere of genuineness, empathy, and unconditional positive regard—nonjudgmental acceptance and respect for the client. And although such concepts may seem to some as mere “feel-good” theorizing, they have solid scientiﬁc support. A recent American Psychological Association task force, charged with finding research-based practices that contribute to the effectiveness of therapy, combed the research literature and found evidence that therapy is most likely to be successful when the therapist provides the Rogerian qualities of empathy, positive regard, genuineness, and feedback (Ackerman et al., 2001). (See Figure 13.1.)

Psychotherapy

Insight therapies Behavior therapies

Psychodynamic Humanistic Cognitive Therapies based Therapies based Therapies based therapies therapies therapies on operant on observational on classical conditioning learning conditioning Freudian Neo-Freudian psychoanalysis therapies

● FIGURE 13.1 Types of Psychotherapy Each of the two major branches of psychotherapy has many variations.

HOW DO PSYCHOLOGISTS TREAT PSYCHOLOGICAL DISORDERS? 535 Cognitive Therapies The insight therapies we have discussed so far focus primarily on people’s emotions or motives. Cognitive therapy, on the other hand, sees rational thinking as the key to therapeutic change. The assumption is that psychological problems arise from erroneous thinking. Cognitive therapy takes several forms, but we will give you some of its ﬂavor with one example: Aaron Beck’s cognitive therapy for depression. Beck, who was originally trained in classical psychoanalysis, broke with the Freudian tradition when he began noticing that the dreams and free associations of his depressed patients were ﬁlled with negative thoughts. Commonly they would make such self-deprecating statements as “Nobody would like me if they really knew me” and “I’m not smart enough to make it in this com- petitive school.” Gradually Beck came to believe that depression occurs because of this negative self-talk. So, says Beck, “The therapist helps the patient to identify his warped thinking and to learn more realistic ways to formulate his experiences” (Beck, 1976, p. 20). Here’s a sample of Beck’s approach, taken from a therapy session with a college student (Beck et al., 1979, pp. 145–146):

CLIENT: I get depressed when things go wrong. Like when I fail a test. THERAPIST: How can failing a test make you depressed? ● A cognitive therapist would say that this CLIENT: Well, if I fail, I’ll never get into law school. student, depressed about a poor grade, may THERAPIST: Do you agree that the way you interpret the results of the test well stay depressed if he berates his own will affect you? You might feel depressed, you might have intelligence rather than reattributing the blame to the situation—a tough test. trouble sleeping, not feel like eating, and you might even won- der if you should drop out of the course. CLIENT: I have been thinking that I wasn’t going to make it. Yes, I agree. THERAPIST: Now what did failing mean? CLIENT: (tearful) That I couldn’t get into law school. THERAPIST: And what does that mean to you? CLIENT: That I’m just not smart enough. THERAPIST: Anything else? CLIENT: That I can never be happy. THERAPIST: And how do these thoughts make you feel? CLIENT: Very unhappy. THERAPIST: So it is the meaning of failing a test that makes you very unhappy. In fact, believing that you can never be happy is a powerful factor in producing unhappiness. So, you get yourself into a trap—by definition, failure to get into law school equals “I can never be happy.” As you can see from this exchange, the cognitive therapist helps the individual confront the destructive thoughts that support depression. Studies have shown that Beck’s approach can be at least as effective as medication in the treatment of depression (Antonuccio, 1995). How might a cognitive therapist approach a 19-year-old obsessive patient? Most likely the focus would be on the irrational beliefs she held, such as the idea that flower pots and vases could, by themselves, fall down in the night ■ Cognitive therapy Emphasizes and break. A cognitive therapist would also challenge the assumption that rational thinking (as opposed to subjective something catastrophic might happen (such as not being able to sleep!) if she emotion, motivation, or repressed conflicts) as didn’t perform a nightly ritual. the key to treating mental disorder. ■ Group therapy Any form of psychotherapy done with more than one client/patient Group Therapies All the treatments we have discussed to this point involve at a time. Group therapy is often done from a one-to-one relationships between a patient or client and therapist. However, humanistic perspective. group therapy can have value in treating a variety of concerns, particularly

536 CHAPTER 13 ❚ THERAPIES FOR PSYCHOLOGICAL DISORDERS problems with social behavior and relationships. This can be done in many ways—with couples, families, or groups of people who have similar problems, such as drug addictions. Usually they meet together once a week, but some innovative therapy groups are even available on the Internet (Davison et al., 2000). Most commonly, group approaches employ a humanistic perspective, although psychodynamic groups are common, too. Among the benefits of group therapy, clients have opportunities to observe and imitate new social behaviors in a forgiving, supportive atmosphere. We will touch on only a small sample of group therapies below: self-help groups and marital and family therapy. Self-Help Support Groups Perhaps the most noteworthy development in group therapy has been the surge of interest in self-help support groups. It is estimated that there are more than 500,000 such groups, which are attended by some 15 million Americans every week (Leerhsen, 1990). Many are free, especially those that are not directed by a health care professional. Such groups give people a chance to meet under nonthreatening conditions to exchange ideas with others who are having similar problems and are surviving and sometimes even thriving (Christensen & Jacobson, 1994; Jacobs & Goodman, 1989; Schiff & Bargal, 2000). One of the oldest, Alcoholics Anonymous (AA), pioneered the self-help concept, beginning in the mid-1930s. Central to the original AA process is the concept of “12 steps” to recovery from alcohol addiction, based not on psychological theory but on the trial-and-error experience of early AA members. The ﬁrst step begins with recognizing that one has become powerless over alcohol; the second affirms that faith in a “greater power” is necessary for recovery. In the remaining steps the individual seeks help from God and sets goals for making amends to those who have been hurt by his or her actions. Members are urged and helped by the group to accept as many of the steps as possible in order to maintain recovery. The feminist consciousness-raising movement of the 1960s brought the self- help concept to a wider audience. As a result, self-help support groups now exist for an enormous range of problems, including ❚ Managing life transition or other crises, such as divorce or death of a child ❚ Coping with physical and mental disorders, such as depression or heart attack ❚ Dealing with addictions and other uncontrolled behaviors, such as alcoholism, gambling, overeating, sexual excess, and drug dependency ❚ Handling the stress felt by relatives or friends of those who are dealing with addictions Group therapy also makes valuable contributions to the treatment of terminally ill patients. The goals of such therapy are to help patients and their families live their lives as fully as possible, to cope realistically with impend- ing death, and to adjust to the terminal illness (Adams, 1979; Yalom & Greaves, 1977). One general focus of such support groups for the terminally ill is to help them learn “how to live fully until you say goodbye” (Nungesser, 1990). Couples and Family Therapy Sometimes the best setting in which to learn about relationships is in a group of people struggling with relationships. Cou- ples counseling (or therapy), for example, may involve one or more couples who are learning to clarify their communication patterns and improve the quality of their interaction (Napier, 2000). By seeing couples together, a ther- ■ Self-help support groups Groups, apist can help the partners identify the verbal and nonverbal styles they use such as Alcoholics Anonymous, that provide social support and an opportunity for sharing to dominate, control, or confuse each other. Each party is taught how to rein- ideas about dealing with common problems. force desired responses in the other and withdraw reinforcement for unde- Such groups are typically organized and run by sirable reactions. Couples are also taught nondirective listening skills to help laypersons, rather than professional therapists.

HOW DO PSYCHOLOGISTS TREAT PSYCHOLOGICAL DISORDERS? 537 the other person clarify and express feelings and ideas (Dattilio & Padesky, 1990; O’Leary, 1987). Couples therapy typically focuses not on the personalities involved but on the processes of their relationship, particularly their patterns of conflict and communication (Gottman, 1994; Greenberg & Johnson, 1988; Notarius & Mark- man, 1993). Difficult as this may be, changing a couple’s interaction patterns can be more effective than individual therapy with one person at a time (Gottman, 1994). In family therapy, the “client” is an entire nuclear family, and each family member is treated as a member of a system of relationships (Fishman, 1993). A family therapist helps troubled family members perceive the issues or patterns that are creating problems for them. The focus is on altering the psychological “spaces” between people and the interpersonal dynamics among people (Foley, 1979; Schwebel & Fine, 1994). Family therapy can not only reduce tensions within a family, but it can also improve the functioning of individual members by helping them recognize their roles in the group. Virginia Satir, a pioneer of family therapy, noted that the therapist, too, has roles to play during therapy. Among them, the therapist acts as an interpreter and clarifier of the interactions that take place in the therapy session, as well as an advisor, mediator, and referee (Satir, 1983; Satir et al., 1991). As in couples therapy, family therapy focuses on the situational rather than the dispositional aspects of a problem. That is, the therapist helps family members look at how they interact, rather than at individual’s motives and intentions. For example, the therapist might point out how one family member’s unemployment affects everyone’s feelings and relationships—rather than seeking to assign blame or label anyone as lazy or selfish. The goal of a family therapy meeting, then, is not to have a “gripe session,” but to develop the family’s ability to come together for constructive problem solving.

Behavior Therapies If the problem is overeating, bed-wetting, shyness, antisocial behavior, or anything else that can be described in purely behavioral terms, the chances Behavior Therapies are good that it can be modified by one of the behavior therapies (also known ● Systematic as behavior modification). Based on the assumption that these undesirable desensitization behaviors have been learned and therefore can be unlearned, behavior ther- ● Aversion therapy apy relies on the principles of operant and classical conditioning. In addition to those difficulties listed above, behavior therapists report success in deal- ● Contingency ing with fears, compulsions, depression, addictions, aggression, and delin- management quent behaviors. ● Token economies Behavior therapists focus on problem behaviors (rather than inner ● Participant thoughts, motives, or emotions). They determine how these behaviors might modeling have been learned and, more important, how they can be eliminated and replaced by more effective patterns. To see how this is done, we will look first at the therapy techniques borrowed from classical conditioning. (See the chart in the margin.) Classical Conditioning Therapies The first example of behavior therapy came from psychologist Mary Cover Jones (1924). Working with a fearful small boy named Peter, she was able to desensitize the boy’s intense fear of a rabbit, over a period of weeks, by gradually bringing the rabbit closer and closer while the ■ Behavior modification Another boy was eating. Eventually, Peter was able to allow the rabbit to sit on his lap term for behavior therapy. while he petted it. (You may notice the similarity to John Watson’s experiments ■ Behavior therapy Any form of psychotherapy based on the principles of on Little Albert. Indeed, Jones was an associate of Watson and knew of the Lit- behavioral learning, especially operant tle Albert study. Unlike Albert, however, Peter came to treatment already pos- conditioning and classical conditioning. sessing an intense fear of rabbits and other furry objects.)

538 CHAPTER 13 ❚ THERAPIES FOR PSYCHOLOGICAL DISORDERS Surprisingly, it was another 14 years before behavior therapy reappeared, this time as a treatment for bed-wetting (Mowrer & Mowrer, 1938). The method involved a ﬂuid-sensitive pad placed under the patient. When moisture set off an alarm, the patient would awaken. The treatment was effective in 75% of cases—an amazing success rate, in view of the dismal failure of psychodynamic therapy to prevent bed-wetting by talking about the meaning of the symptom. Yet it took another 20 years before behavior therapy entered the mainstream of psychological treatment. Why the delay? The old Freudian idea—that every symptom has an underlying, unconscious cause that must be discovered and eradicated—was extremely well rooted in clinical lore. Therapists dared not attack symptoms (behaviors) directly for fear of symptom substitution: the idea that when one symptom was eliminated, another, which might be much worse, could take its place. It took the psychiatrist Joseph Wolpe to challenge that en- trenched notion. Systematic Desensitization Wolpe reasoned that the development of irrational fear responses and other undesirable emotion- ally based behaviors seems to follow the classical conditioning model. As you will recall, classical conditioning involves the association of a new stimulus with an unconditioned stimulus, so that the person responds the same way to both. Wolpe also realized another simple truth: The nervous system cannot be relaxed and agitated at the same time, because these two incompatible pro- CONNECTION CHAPTER 6 cesses cannot be activated simultaneously. These two ideas, then, became the In classical conditioning, a CS comes to basis for systematic desensitization (Wolpe, 1958, 1973). produce essentially the same response as His method begins with a training program that teaches his patients to relax the UCS. their muscles and their minds (Rachman, 2000). While patients are in this deeply relaxed state, he helps them extinguish their fears by having them imagine fearful situations. They do so in gradual steps that move from remote associations of the feared situation to direct images of it. In the process of systematic desensitization, the therapist and client ﬁrst identify the stimuli that provoke anxiety and arrange them in a hierarchy ranked from weakest to strongest (Shapiro, 1995). For example, a patient suf- ■ Systematic desensitization fering from severe fear of public speaking constructed the hierarchy of uncon- A behavioral therapy technique in which ditioned stimuli shown in Table 13.2. During desensitization, the relaxed client anxiety is extinguished by exposing the vividly imagines the weakest anxiety stimulus on the list. If the stimulus can be patient to an anxiety-provoking stimulus.

TABLE 13.2 A Sample Anxiety Hierarchy

The following is typical of anxiety hierarchies that a therapist and a patient might develop to desensitize a fear of public speaking. The therapist guides the deeply relaxed patient in imagining the following situations: 1. Seeing a picture of another person giving a speech 2. Watching another person give a speech 3. Preparing a speech that I will give 4. Having to introduce myself to a large group 5. Waiting to be called upon to speak in a meeting 6. Being introduced as a speaker to a group 7. Walking to the podium to make a speech 8. Making a speech to a large group

HOW DO PSYCHOLOGISTS TREAT PSYCHOLOGICAL DISORDERS? 539 visualized without discomfort, the client goes on to the next stronger one. After a number of sessions, the client can imagine the most distressing situations on the list without anxiety (Lang & Lazovik, 1963)—hence the term systematic desensitization. In some forms of systematic desensitization, called exposure therapy, the therapist may actually have the patient confront the feared object or situation, such as a spider or a snake, rather than just imagining it. You will recall that Sabra, whom you met in the story opening Chapter 6, went through a form of desensitization to deal with her fear of flying. A number of studies have shown that desensitization works remarkably ● In “virtual reality,” phobic patients can well with phobic patients (Smith & Glass, 1977). Desensitization has also been confront their fears safely and conveniently in the behavior therapist’s office. On a successfully applied to a variety of fears, including stage fright and anxiety about screen inside the headset, the patient sees sexual performance (Kazdin, 1994; Kazdin & Wilcoxin, 1976). Recently, psy- computer-generated images of feared sit- chologists have added a high-tech twist by using computer-generated images uations, such as seeing a snake, flying in an that expose phobic patients to fearful situations in a safe virtual-reality envi- airplane, or looking down from the top of a ronment (Hoffman, 2004; Rothbaum & Hodges, 1999; Rothbaum et al., 2000a). tall building. Aversion Therapy Clearly, desensitization therapy helps clients deal with stimuli that they want to avoid. But what about the reverse? What can be done to help those who are attracted to stimuli that are harmful or illegal? Examples include drug addiction, certain sexual attractions, and tendencies to violence— UCS (foul odor) all problems in which deviant behavior is elicited by some specific stimulus. UCR Aversion therapy tackles these problems with a conditioning procedure (nausea) designed to make tempting stimuli less provocative by pairing them with CR unpleasant (aversive) stimuli. For example, the aversive stimuli could be elec- CS tric shocks or nausea-producing drugs, whose effects are highly unpleasant but (cigarette smoke) not in themselves dangerous to the client. In time, the negative reactions (unconditioned responses) associated with the aversive stimuli come to be associated with the conditioned stimuli (such as an addictive drug), and the ● FIGURE 13.2 Conditioning an person develops an aversion that replaces the desire. Aversion for Cigarette Smoke To give another example, if you were to elect aversion therapy to help Aversion therapy for smoking might simultaneously pair a foul odor with cigarette smoke you quit smoking, you might be required to chain-smoke cigarettes while hav- blown in the smoker’s face. The foul odor ing a foul odor blown in your face—until you develop a strong association (such as rotten eggs) produces nausea. This between smoking and nausea. (see Figure 13.2). A similar conditioning effect response then becomes the conditioned occurs in alcoholics who drink while taking Antabuse, a drug often prescribed response associated with cigarette smoke. to encourage sobriety. (Source: From THE PRACTICE OF BEHAVIOR THERAPY 4th ed. by Joseph Wolpe. Copyright In some ways, aversion therapy resembles nothing so much as torture. So © 1990 by Allyn & Bacon. Reprinted by Allyn why would anyone submit voluntarily to it? Usually people do so only because & Bacon, Boston, MA) they have unsuccessfully tried other treatments. In some cases, people may be required to enter aversion therapy by the courts or as part of a treatment program while in prison.

CONNECTION CHAPTER 6 Operant Conditioning Therapies Johnny has a screaming ﬁt when he goes to In operant conditioning, behavior changes the grocery store with his parents and they refuse to buy him candy. His because of consequences, such as behavior is an example of a problem that has been acquired by operant con- rewards and punishments. ditioning—he has been rewarded when his parents have given in to his demands. In fact, many behavior problems found in both children and adults ■ Exposure therapy A form of desen- have been shaped by rewards and punishments. Consider, for example, the sitization therapy in which the patient directly similarities between Johnny’s case and the employee who chronically arrives confronts the anxiety-provoking stimulus (as late for work or the student who waits until the last minute to study for a test. opposed to imagining the stimulus). Behavior therapists argue that changing such behaviors requires operant con- ■ Aversion therapy As a classical conditioning procedure, aversive counter- ditioning techniques. Let’s look at two variations on this theme. conditioning involves presenting individuals with an attractive stimulus paired with Contingency Management Johnny’s parents may learn to extinguish his ﬁts at unpleasant (aversive) stimulation in order the grocery store by simply withdrawing their attention—no easy task, by the to condition revulsion. way. In addition, the therapist may coach them to “catch Johnny being good”

540 CHAPTER 13 ❚ THERAPIES FOR PSYCHOLOGICAL DISORDERS DO IT YOURSELF! Behavior Self-Modification

Is there a behavior you would like to engage when you want to initiate the behavior (for Your reward: ______in more often than you do—studying, initiating example: in class, when relaxing with friends, ______conversations with others, exercising to keep ﬁt? or at a certain time every morning). Give yourself feedback on your progress by Write this in behavioral terms on the line below. The time or conditions for the new keeping a daily record of the occurrence of your (No fair using mentalistic words, such as “feel- behavior: ______new behavior. This could be done, for example, ing” or “wanting.” Behaviorists require that you ______keep things objective by specifying only an on a calendar or a graph. In time, you will observable behavior.) To increase your likelihood of producing discover that the desired behavior has increased the desired response, apply some positive in frequency. You will also ﬁnd that your new The desired new behavior: ______reinforcement therapy to yourself. Choose an habit carries its own rewards, such as better ______appropriate reward that you will give yourself grades or more satisfying social interactions When or under what conditions would you when you have produced the desired behavior (Kazdin, 1994). like to engage in this new behavior? On the line at the appropriate time. Write the reward that below, write in the time or stimulus conditions you will give yourself on the line below.

and give him the attention he needs then. Over time, the changing contingencies will work to extinguish the old, undesirable behaviors and help to keep the new ones in place. This approach is an example of contingency management: changing behavior by modifying its consequences. It has proved effective in managing behavior problems found in many settings, including families, schools, prisons, the military, and mental hospitals. To give another example, the care- ful application of reward and punishment can dramatically reduce the self-destructive behaviors in autistic children (Frith, 1997). You can also apply contingency management techniques to yourself, if you would like to change some undesirable habit: See the accompanying box, “Do It Your- self! Behavior Self-Modification.” One caution is in order: Although some people misbehave merely because they want attention, simply giving more ● A patient undergoes a simplified form of attention can be counterproductive. For example, overzealous parents and aversion therapy in which overexposure to smoke makes her nauseous. The smell of teachers may be tempted to praise children lavishly, even when their perfor- smoke and smoking behavior then take on mance has been mediocre—under the mistaken impression that the extra praise unpleasant associations. will increase low self-esteem and boost performance. In such cases, parents and teachers can aggravate behavior problems by increasing rewards (Viken & McFall, 1994). How could this be? What the child actually learns is that more rewards can be “earned” by producing fewer and fewer desirable behaviors. One must, therefore, take care in simply piling on more rewards. The key to success lies in tying rewards more closely to (making them contingent on) desirable behaviors. Token Economies The special form of therapy called a token economy is the ■ behavioral version of group therapy. It commonly finds application in class- Contingency management An operant conditioning approach to changing rooms and institutions (Ayllon & Azrin, 1968; Martin & Pear, 1999). The behavior by altering the consequences, es- method takes its name from the plastic tokens sometimes awarded by thera- pecially rewards and punishments, of behavior. pists or teachers as immediate reinforcers for desirable behaviors. In a class- ■ Token economy An operant tech- room, earning a token might mean sitting quietly for several minutes, partici- nique applied to groups, such as classrooms pating in a class discussion, or turning in an assignment. Later, recipients may or mental hospital wards, involving the distribution of “tokens” or other indicators of redeem the tokens for food, merchandise, or privileges. Often, “points” or play reinforcement contingent on desired behaviors. money are used in place of tokens. The important thing is that the individual The tokens can later be exchanged for receive something as a reinforcer immediately after giving desired responses. privileges, food, or other reinforcers.

HOW DO PSYCHOLOGISTS TREAT PSYCHOLOGICAL DISORDERS? 541 ■ Participant modeling A social- The token economy approach has also been found to work well in encour- learning technique in which a therapist aging prosocial behaviors among mental patients and prisoners (Schaefer & demonstrates and encourages a client to Martin, 1966). In these settings, the token reinforcers might be exchanged for imitate a desired behavior. ■ Cognitive–behavioral therapy cigarettes, reading material, or better living conditions. A PsychInfo search A newer form of psychotherapy that combines reveals that in the last 10 years alone, over 100 published studies attest to the the techniques of cognitive therapy with those effectiveness of the token economy in shaping desirable behavior. of behavior therapy. Participant Modeling: An Observational-Learning Therapy “Monkey see— monkey do,” we say. And sure enough, monkeys learn fears by observation and imitation. One study showed that laboratory monkeys with no previous aversion to snakes could acquire a simian version of ophidiophobia by observing their parents reacting fearfully to real snakes and toy snakes. (You don’t remember that one? Look back at Table 12.3 on page 494.) The more disturbed the parents were at the sight of the snakes, the greater the resulting fear in their offspring (Mineka et al., 1984). A follow-up study showed that such fears were not just a family matter. When other monkeys that had previously shown no fear of snakes were given the opportunity to observe unrelated adults CONNECTION CHAPTER 6 responding to snakes fearfully, they quickly acquired the same response, as Participant modeling is based on Ban- you can see in Figure 13.3 (Cook et al., 1985). dura’s theory of observational learning. Like monkeys, people also learn fears by observing the behavior of others. Participant modeling takes advantage of this propensity for observational learning by having the client, or participant, observe and imitate another per- Real son who is modeling desirable behaviors. Coaches, of course, often use partici- Toy pant modeling to teach their athletes new skills. Likewise, participant modeling Neutral has proved of value in therapy, where the therapist may model the behavior object and encourage the client to imitate it. For example, in treating a phobia for Pretest snakes, a therapist might ﬁrst approach a caged snake, then touch the snake, and so on. (Because snake phobias are so common, they are often the subject Observe fearful models of behavior therapy demonstrations.) The client then imitates the modeled behavior but at no time is forced to perform. If the therapist senses resistance, the client may return to a previously successful, less-threatening behavior. As you can see, the procedure is similar to systematic desensitization, with the Posttest important addition of observational learning. In fact, participant modeling draws on concepts from both operant and classical conditioning. The power of participant modeling in eliminating snake phobias can be seen in a study that compared the participant modeling technique with several other approaches: (1) symbolic modeling, a technique in which subjects receive indi- rect exposure by watching a ﬁlm or video in which models deal with a feared situation; (2) desensitization therapy, which, as you will remember, involves 3-month follow-up 0 2 4 6 exposure to an imagined fearful stimulus; and (3) no therapeutic intervention (the control condition). As you can see in Figure 13.4, participant modeling was Number of fear behaviors the most successful. The snake phobia was eliminated in 11 of the 12 subjects in the participant modeling group (Bandura, 1970).

● FIGURE 13.3 Fear Reactions in Monkeys Cognitive–Behavioral Therapy: A Synthesis After young monkeys raised in laboratories Suppose you are having difficulty controlling feelings of jealousy every time observe unrelated adult monkeys showing your mate is friendly with someone else. Chances are that the problem origi- a strong fear of snakes, they are vicariously conditioned to fear real snakes and toy snakes nates in your cognitions about yourself and the others involved (“Marty is with an intensity that persists over time. stealing Terry away from me!”) These thoughts may also affect your behavior, (Source: From “Observational Conditioning making you act in ways that could drive Terry away from you. A dose of ther- of Snake Fear in Unrelated Rhesus Monkeys” apy aimed at both your cognitions and your behaviors may be a better bet than by M. Cook, S. Mineka, B. Wokenstein, and K. either one alone. Laitsch, Journal of Abnormal Psychology, 94, pp. 591–610. Copyright © 1985 by American In brief, cognitive–behavioral therapy combines a cognitive emphasis on Psychological Association. Reprinted by per- thoughts and attitudes with the behavioral strategies that we discussed earlier. mission of American Psychological Association.) This dual approach assumes that an irrational self-statement often underlies

542 CHAPTER 13 ❚ THERAPIES FOR PSYCHOLOGICAL DISORDERS ● FIGURE 13.4 Participant Modeling Therapy 28 participant modeling The subject shown in the photo ﬁrst watches 26 symbolic modeling a model make a graduated series of snake- approach responses and then repeats them 24 desensitization herself. Eventually, she can pick up the snake 22 control and let it move about on her. The graph compares the number of approach responses 20 subjects made before and after receiving 18 participant modeling therapy (most effective) with the behavior of those exposed to two 16 other therapeutic techniques and a control 14 group. (Source: From “Modeling Therapy” by D. Albert Bandura. Reprinted by permission of 12 the author.) Mean approach responses 10 8

Pretest Posttest

maladaptive behavior. For example, an addicted smoker might automatically tell himself, “One more cigarette won’t hurt me” or “I’ll go crazy if I don’t have a smoke now.” These irrational self-statements must be changed or replaced with rational, constructive coping statements before the unacceptable behavior pattern can be modiﬁed. Here is an example of healthier thinking: “I can get through this craving if I distract myself with something else I like to do, like going to a movie.” In cognitive–behavioral treatment, the therapist and client work together to modify irrational self-talk, set attainable behavioral goals, develop realistic strategies for attaining them, and evaluate the results. In this way, people change the way they approach problems and gradually develop new skills and a sense of self-efficacy (Bandura, 1986, 1992; Schwarzer, 1992). Rational–Emotive Behavior Therapy: Challenging the “Shoulds” and “Oughts” One of the most famous (some would say “notorious”) forms of cognitive– behavioral therapy was developed by the colorful Albert Ellis (1987, 1990, 1996) to help people eliminate self-defeating thought patterns. Ellis has dubbed his treatment rational–emotive behavior therapy (REBT), a name derived from its method of challenging certain “irrational” beliefs and behaviors. What are the irrational beliefs challenged in REBT, and how do they lead to maladaptive feelings and actions? According to Ellis, maladjusted individuals base their lives on a set of unrealistic values and unachievable goals. These “neurotic” goals and values lead people to hold unrealistic expectations that they should always succeed, that they should always receive approval, that they CONNECTION: CHAPTER 10 should always be treated fairly, and that their experiences should always be Compare with Karen Horney’s neurotic pleasant. (You can see the most common irrational beliefs in the accompany- trends. ing box, “Do It Yourself! Examining Your Own Beliefs.”) For example, in your own daily life, you may frequently tell yourself that you “should” get an A in math or that you “ought to” spend an hour exercising every day. Further, he says, if you are unable to meet your goals and seldom question this neurotic ■ self-talk, it may come to control your actions or even prevent you from choos- Rational–emotive behavior therapy (REBT) Albert Ellis’s brand of ing the life you want. If you were to enter REBT, your therapist would teach cognitive therapy, based on the idea that you to recognize such assumptions, question how rational they are, and replace irrational thoughts and behaviors are the faulty ideas with more valid ones. Don’t “should” on yourself, warns Ellis. cause of mental disorders.

HOW DO PSYCHOLOGISTS TREAT PSYCHOLOGICAL DISORDERS? 543 DO IT YOURSELF! Examining Your Own Beliefs

It may be obvious that the following are not ______6. I must constantly be on my guard In Ellis’s view, all these statements are healthy beliefs, but Albert Ellis finds that many against dangers and things that irrational beliefs that can cause mental prob- people hold them. Do you? Be honest: Put a could go wrong. lems. The more items you have checked, the check mark beside each of the following state- ______7. Life is full of problems, and I more “irrational” your beliefs. His cognitive ments that accurately describes how you feel must always find quick solutions approach to therapy, known as rational–emotive about yourself. to them. behavior therapy, concentrates on helping ______8. It is easier to evade my problems people see that they can “drive themselves ______1. I must be loved and approved by crazy” with such irrational beliefs. For example, everyone. and responsibilities than to face them. a student who parties rather than studying for a ______2. I must be thoroughly competent, test holds irrational belief #8. A person who adequate, and achieving. ______9. Unpleasant experiences in my past have had a profound influ- is depressed about not landing a certain job ______3. It is catastrophic when things do ence on me. Therefore, they must holds irrational belief #3. You can obtain more not go the way I want them to go. continue to influence my current information on Ellis’s system from his books. ______4. Unhappiness results from forces feelings and actions. over which I have no control. ______10. I can achieve happiness by just ______5. People must always treat each other enjoying myself each day. The fairly and justly; those who don’t future will take care of itself. are nasty and terrible people.

How might a cognitive–behavioral therapist have dealt with Freud’s obsessive patient? First, donning a cognitive “thinking cap,” the therapist would challenge the girl’s irrational beliefs, as we suggested earlier. Then, switching to a behaviorist’s hat, the therapist might teach the girl relaxation techniques to use when she began to get ready for bed each evening. These techniques then would substitute for the obsessive ritual. It is also likely that the therapist would work with the parents (as might the psychodynamic therapist), focusing on helping them learn not to reward the girl with attention for her ritual behavior. Changing the Brain by Changing the Mind Research now shows that cognitive–behavioral therapy may not only help people change their minds but also change the brain itself. In one study, patients who suffered from obsessions about whether they had turned off their stoves or locked their doors, for example, were given cognitive behavior modiﬁcation (Schwartz et al., 1996). When they felt an urge to run home and check on themselves, they were trained to relabel their experience as an obsession or compulsion—not a rational concern. They then focused on waiting out this “urge” rather than giving in to it, by distracting themselves with other activities for about 15 minutes. Positron emission tomography (PET) scans of the brains of subjects who were trained in this technique indicated that, over time, the part of the brain responsible for that nagging fear or urge gradually became less active. As this study shows, the mind can ﬁx the brain!

Evaluating the Psychological Therapies Now that we have looked at a variety of psychological therapies (see Figure 13.5), let us step back and ask how well therapy works. Does it really make a difference? The answer to this question hasn’t always been clear (Kopta et al., 1999; Shadish et al., 2000). Think about it: How could you tell whether therapy works? Lots of evidence says that people who have undergone therapy like it. This was shown in a survey involving thousands of subscribers to Consumer Reports (1995). Respondents indicated how much their treatment helped, how satisﬁed they

544 CHAPTER 13 ❚ THERAPIES FOR PSYCHOLOGICAL DISORDERS ego

superego id

Behavior therapies Psychodynamic therapies Humanistic therapies aim to change things outside the aim to make changes inside the aim to change the way people individual—rewards, punishments, person’s mind, especially the see themselves. and cues in the environment—in unconscious. order to change the person’s external behaviors

Cognitive therapies Group therapies Biomedical therapies aim to change the way people aim to change the way people aim to change the structure think and perceive. interact. or function of the brain.

● FIGURE 13.5 A Comparison of Different Types of Therapy were with the therapist’s treatment of their problems, how much their “overall emotional state” changed following therapy, as well as what kind of therapy they had undergone. For about 3000 of the 7000 respondents, therapy consisted of talking to friends, to relatives, or to clergy (as might be expected from our discussion earlier in this chapter). Another 2900 saw a mental health professional; the rest saw family doctors or support groups. Among the results: (a) Therapy works—that is, it was perceived to have helped clients diminish or eliminate their psychological problems; (b) long-term therapy is better than short-term therapy; and (c) all forms of therapy are about equally effective for improving clients’ problems (see Jacobson & Christensen, 1996; Kazdin, 1986; Seligman, 1995). We can’t give a thumbs-up to therapy, however, merely because people say they like it or that it helped them (Hollon, 1996). Testimonials don’t make for good science—which is why psychologists now demand that therapy be judged by studies having a comparison group or control group. Let’s turn, there- CONNECTION CHAPTER 2 fore, to the controlled studies of therapy’s effectiveness. A control group is treated exactly as the experimental group, except for the crucial Eysenck’s Controversial Proclamation The issue of therapy’s effectiveness independent variable. came to a head in 1952. After reviewing the existing evidence, British psychologist Hans Eysenck shook the therapeutic world with the claim that

HOW DO PSYCHOLOGISTS TREAT PSYCHOLOGICAL DISORDERS? 545 roughly two-thirds of all people with nonpsychotic problems recover within two years of the onset of the problem, whether they get therapy or not. The evidence came from a review of several outcome studies of various kinds of insight therapy, all of which compared patients who received therapy to those who were on waiting lists, awaiting their turn in therapy. What Eysenck noted, then, is that people on the waiting lists got better at the same rate as those in therapy. This meant that psychotherapy is essentially worthless—no better than having no treatment at all. To say the least, this wasn’t a happy prospect for therapists. Eysenck’s challenge had a most important result: It stimulated therapists to do a great deal of research on the effectiveness of therapy. And, as we will see, the discoveries that were made underscore the value of repli- cation of research as a crucial part of the scientiﬁc method.

In Response to Eysenck Major reviews of the accumulating evidence on therapy began to be reported in 1970 (by Meltzoff & Kornreich), in 1975 (by Luborsky et al.), and in 1977 (by Smith and Glass). Overall, this literature— numbering some 375 studies—supported two major conclusions. First, therapy is, after all, more effective than no therapy. And second, Eysenck had over- estimated the improvement rate in no-therapy control groups. Gradually, then, a consensus supporting the value of psychotherapy emerged (Meredith, 1986; VandenBos, 1986). Moreover, the newest research began to show that therapy was effective not only in Western industrialized countries (in the United States, Canada, and Europe) but also in a variety of cultural settings throughout the world (Beutler & Machado, 1992; Lipsey & Wilson, 1993). A number of writers have cautioned, however, that therapists must be sensitive to cultural differences and adapt their techniques appropri- ately (Matsumoto, 1996; Shiraev & Levy, 2001).

New Questions The new studies have, however, raised new questions. Are some therapies better than others? Can we identify therapies that are best suited for treating specific disorders? The Smith and Glass survey (1977) hinted that the answers to those questions were “Yes” and “Yes.” Smith and Glass found that the behavior therapies seemed to have an advantage over insight therapies for the treatment of many anxiety disorders. More recent evaluations have found that insight therapies can also be used effectively to treat certain problems, such as marital discord and depression. Indeed, there is a clear trend toward matching specific therapies to specific conditions. It is important to realize, however, that these therapeutic techniques do not necessarily “cure” psychological disorders. In the treatment of schizophrenia, mental retarda- tion, or autism, for example, psychological therapies may be deemed effective when people suffering from these afflictions learn more adaptive behaviors (Hogarty et al., 1997; Lovaas, 1993; Wolpe, 1985).

Consensus and Controversy on Effective Therapies The American Psycho- logical Association has sponsored a special task force charged with evaluating psychological therapies (Chambless et al., 1996; Nathan, 1998; “Task Force,” 1993). The thrust of their findings is that more and more specific disorders— literally dozens of them—can be treated successfully by specific therapies that have been validated in well-designed experiments (Barlow, 1996). Here are some examples of therapies pronounced effective by this group: ❚ Behavior therapy for specific phobias, enuresis (bedwetting), autism, and alcoholism ❚ Cognitive–behavioral therapy for chronic pain, anorexia, bulimia, agoraphobia, and depression ❚ Insight therapy for couples’ relationship problems

546 CHAPTER 13 ❚ THERAPIES FOR PSYCHOLOGICAL DISORDERS More recently, a report by the American Psychological Association focused specifically on evidence-based treatments for depression (Hollon et al., 2003). That document asserts that several varieties of psychotherapy can be effective. These include cognitive, behavior, and family therapy. The APA report also acknowledged that there is a legitimate role for both drug and electroconvulsive therapies in the treatment of depression. In fact, some studies suggest that for depression, a combination of cognitive–behavioral therapy and drug therapy can have a greater effect than either treatment alone (Keller et al., 2000). Surprisingly, perhaps, the movement to identify therapies that work has generated spirited discussion among therapists (Glenn, 2003). Researchers find that a common element in successful therapy is a caring, hopeful relationship and a new way of looking at oneself and the world (Barker et al., 1988; Jones et al., 1988). This conclusion has been supported by a more recent study that found the effectiveness of therapy to depend less on the type of therapy used and more on the quality of the relationship between therapist and client (Blatt, Sanislow, & Pilkonis, 1996). Some practitioners fear that they will become locked into a therapeutic straitjacket by insurance companies, which will be unwilling to pay for any treatments not on the official list or for any devia- tions from “approved” treatments, no matter what the needs of the individual patient. On the other side of the issue are those who fear that nonmedical therapists will be squeezed out of the picture by drug-prescribing physicians. To end this discussion on a more encouraging note: A recent study of 200 practitioners found that psychologists tend to modify their approach to treatment to fit the needs of their clients, as the situation unfolds during counseling or psychotherapy (Holloway, 2003b). That is, despite our emphasis in this chapter on conflicting opinions about treatment of psychological disorders, most practitioners are quite willing to adapt their methods to the individual client, rather than holding rigidly to a particular theoretical orientation. And that is good news, indeed, coming from a field that has traditionally had strongly divided allegiances. It appears that the emphasis on science-based practice is finally breaking down the old therapeutic boundaries.

PSYCHOLOGY IN YOUR LIFE: WHERE DO MOST PEOPLE GET HELP? The effectiveness of psychotherapy for a variety of problems seems to be established beyond doubt. Having said that, we should again acknowledge that most people experiencing mental distress do not turn to professional therapists for help. Rather they turn to “just people” in the community (Wills & DePaulo, 1991). Those suffering from mental problems often look to friends, clergy, hairdressers, bartenders, and others with whom they have a trusting relationship. In fact, for some types of problems—perhaps the commonest problems of everyday living—a sympathetic friend may be just as effective as a trained professional therapist (Berman & Norton, 1985; Christensen & Jacob- son, 1994). To put the matter in a different way: Most mental problems are not the crippling disorders described in the previous chapter. Rather, the psychological difficulties most of us face result from lost jobs, difficult marriages, mis- behaving children, friendships gone sour, loved ones dying... In brief, the most familiar problems involve chaos, confusion, choice, frustration, stress, and loss. People who ﬁnd themselves in the throes of these adjustment difficulties may not need extensive psychotherapy, medication, or some other

HOW DO PSYCHOLOGISTS TREAT PSYCHOLOGICAL DISORDERS? 547 special treatment. They need someone to help them sort through the pieces of their problems. Usually this means that they turn to someone like you. What can you do when someone asks you for help? First, you should realize that some problems do indeed require immediate professional treatment. These include a suicide threat or an indication of intent to harm others. You should not delay finding competent help for someone with such tendencies. Second, you should remember that most therapy methods require special training, especially those calling for cognitive–behavioral therapy techniques or psychodynamic interpretations. We urge you to learn as much as you can about these methods—but we strongly recommend that you leave them to the professionals. Some other techniques, however, are simply extensions of good human relationships, and they fall well within the layperson’s ability to administer mental “first aid.” Briefly, we will consider three of these: ❚ Listening: You will rarely go wrong if you just listen. Sometimes listening is all the therapy a person in distress needs. It works by encouraging the speaker to organize a problem well enough to communicate it. As a result, those who talk out their problems frequently arrive at their own solutions. As an active listener, you take the role a step further by giving the speaker feedback: nodding, maintaining an expression that shows interest, paraphrasing, and asking for clarification when you don’t understand. As we saw in the client-centered therapy excerpt on pages 534–535, active listening lets the speaker know that the listener is interested and empathetic (in tune with the other person’s feelings). At the same time, you will do well to avoid the temptation to give advice. Advice robs the recipient of the opportunity to work out his or her own solutions. ❚ Acceptance: Nondirective therapists call this a nonjudgmental attitude. It means accepting the person and the problem as they are. It also means suppressing shock, disgust, or condemnation that would create a hostile climate for problem solving. ❚ Exploration of alternatives: People under stress may see only one course of action, so you can help by identifying other potential choices and explor- ing the consequences of each. (You can point out that doing nothing is also a choice.) Remember that, in the end, the choice of action is not up to you but to the individual who owns the problem. ■ Active listener A person who gives Beyond these basic helping techniques lies the territory of the trained the speaker feedback in such forms as nodding, paraphrasing, maintaining an expression that therapist. Again, we strongly advise you against trying out the therapy tech- shows interest, and asking questions for niques discussed in this chapter for any of the serious psychological disor- clarification. ders discussed in the previous chapter or listed in the DSM-IV.

CHECK YOUR UNDERSTANDING

1. RECALL: Counterconditioning is based on the principles of a. pairing food with punishment. a. operant conditioning. b. having the child observe someone else coming home on time b. classical conditioning. and being rewarded. c. social learning. c. pairing food with rewards. d. cognitive learning. d. having the child relax and imagine being home on time for e. observational learning. dinner. e. refusing to let the child have dinner. 2. APPLICATION: You could use contingency management to change the behavior of a child who comes home late for dinner by

548 CHAPTER 13 ❚ THERAPIES FOR PSYCHOLOGICAL DISORDERS 3. RECALL: A primary goal of psychoanalysis is to 6. RECALL: Eysenck caused a furor with his claim that people who a. change behavior. receive psychotherapy b. reveal problems in the unconscious. a. are just looking for a paid friend. c. overcome low self-esteem. b. really should seek medical treatment for their disorders. d. help the client learn how to get along with others. c. are usually just pampered rich people who have nothing better e. alter interior thought processes. to do with their lives. d. get better no more often than people who receive no therapy 4. RECALL: Carl Rogers invented a technique to help people see their at all. own thinking more clearly. Using this technique, the therapist para- e. respond only to psychoanalysis. phrases the client’s statements. Rogers called this a. client-centered therapy. 7. UNDERSTANDING THE CORE CONCEPT: A phobia would b. reﬂection of feeling. be best treated by ______, whereas a problem of choosing a major c. unconditional positive regard. would be better suited for ______. d. self-actualization. a. behavioral therapy/insight therapy e. analysis. b. cognitive therapy/psychoanalysis c. insight therapy/behavioral therapy 5. RECALL: Which form of therapy directly confronts a client’s self- d. humanistic therapy/behavioral therapy defeating thought patterns? e. psychoanalysis/humanistic therapy a. humanistic therapy b. behavioral therapy c. participant modeling

d. psychoanalytic therapy

a d e b b e b 7. 7. 6. 5. 4. 3. 2.

e. rational–emotive behavior therapy 1. ANSWERS:

HOW IS THE BIOMEDICAL APPROACH USED TO TREAT PSYCHOLOGICAL DISORDERS? The mind exists in a delicate biological balance. It can be upset by irregulari- ties in our genes, hormones, enzymes, and metabolism, as well as by damage from accidents and disease. When something goes wrong with the brain, we can see the consequences in abnormal patterns of behavior or peculiar cognitive and emotional reactions. The biomedical therapies, therefore, attempt to treat these mental disorders by intervening directly in the brain. Our Core Con- cept speciﬁes the targets of these therapies:

Biomedical therapies seek to treat psychological disorders by changing the brain’s chemistry with drugs, its circuitry with surgery, or its patterns of activity with pulses of electricity or powerful magnetic ﬁelds.

Each of the biomedical therapies emerges from the medical model of abnormal mental functioning, which assumes an organic basis for mental illnesses and treats them as diseases—as we saw in Chapter 12. We begin our exami- nation of these biomedical therapies with the powerful arsenal of prescription psychoactive drugs.

Drug Therapy/Psychopharmacology In the history of the treatment of mental disorder, nothing has ever rivaled the revolution created by the discovery of drugs that could calm anxious patients, ■ Psychopharmacology The pre- restore contact with reality in withdrawn patients, and suppress hallucinations scribed use of drugs to help treat symptoms in psychotic patients. This brave new therapeutic era began in 1953 with the of mental illness ostensibly to ensure that indi- introduction of the ﬁrst antipsychotic drugs (often called tranquilizers). As viduals are more receptive to talk therapies.

HOW IS THE BIOMEDICAL APPROACH USED TO TREAT PSYCHOLOGICAL DISORDERS? 549 these drugs found wide application, many unruly, assaultive patients almost miraculously became cooperative, calm, and sociable. In addition, many thought-disordered patients, who had previously been absorbed in their delusions and hallucinations, began to respond to the physical and social environment around them. The effectiveness of drug therapy had a pronounced effect on the census of the nation’s mental hospitals. In 1955, over half a million Americans were living in mental institutions, each staying an average of several years. Then, with the introduction of tranquilizers, the numbers began a steady decline. In just over 10 years, fewer than half the number of the coun- try’s formerly hospitalized mental patients actually resided in mental hospitals, and those who did were usually kept for only a few months. ● What will be the effect of prescribing mood-altering drugs such as Drug therapy has long since steamrolled out of the mental Prozac to millions of people? hospital and into our everyday lives. Currently, millions of people take drugs for anxiety, stress, depression, hyperactivity, insomnia, fears and phobias, obsessions and compulsions, addictions, and numerous other problems. Clearly, a drug-induced revolution has occurred. Drug Therapies But what are these miraculous drugs? ● Antipsychotic You have probably heard of Prozac and Valium, but those are just two of drugs scores of psychoactive drugs that can alter your mood, your perceptions, your ● Antidepressants desires, and perhaps your basic personality. Here we will consider four major and mood categories of drugs used today: antipsychotics, antidepressants and mood stabiliz- stabilizers ers, antianxiety drugs, and stimulants. (See the chart in the margin.) ● Antianxiety drugs Antipsychotic Drugs The purpose of the antipsychotic drugs is to treat the ● Stimulants symptoms of psychosis: delusions, hallucinations, social withdrawal, and agitation (Dawkins et al., 1999; Gitlin, 1990; Holmes, 2001; Kane & Marder, 1993). Most work by reducing the activity of the neurotransmitter dopamine in the brain—although the precise reason why this has an antipsychotic effect is not known. For example, chlorpromazine (sold under the brand name Thorazine) and haloperidol (brand name: Haldol), for example, are known to block dopamine receptors in the synapse between nerve cells. A newer antipsychotic drug, clozapine (Clozaril), both decreases dopamine activity and increases the activity of another neurotransmitter, serotonin, which inhibits the dopamine system (Javitt & Coyle, 2004; Sawa & Snyder, 2002). These drugs reduce overall brain activity, but they do not merely “tranquilize” the patient. Rather, they CONNECTION CHAPTER 12 reduce the positive symptoms of psychosis, although they do little for the Positive symptoms of schizophrenia social distance, jumbled thoughts, and poor attention spans seen in patients include active hallucinations, delusions, with negative symptoms of schizophrenia (Wickelgren, 1998b). and extreme emotions; negative symp- Unfortunately, long-term administration of antipsychotic drugs can have toms include withdrawal and “ﬂat” emotions. several negative side effects. Physical changes in the brain have been noted (Gur & Maany, 1998). Most worrisome is tardive dyskinesia, which produces an incurable disturbance of motor control, especially of the facial muscles. Although the newer drug, clozapine, has reduced motor side effects because of its more selective dopamine blocking, its use involves a small risk of agran- ulocytosis, a blood disease caused by bone marrow dysfunction. With the possibility of such side effects, are antipsychotic drugs worth the risk? There is no ■ Antipsychotic drugs Medicines that easy answer. The risks must be weighed against the severity of the patient’s diminish psychotic symptoms, usually by their effect on the dopamine pathways in the brain. current suffering. ■ Tardive dyskinesia An incurable disorder of motor control, especially involving Antidepressants and Mood Stabilizers The drug therapy arsenal also includes muscles of the face and head, resulting from several compounds that have revolutionized the treatment of depression and long-term use of antipsychotic drugs. bipolar disorder. As with other psychoactive drugs, neither the antidepressants

550 CHAPTER 13 ❚ THERAPIES FOR PSYCHOLOGICAL DISORDERS nor the mood stabilizers can provide a “cure.” Their use, however, has made a big difference in the lives of many people suffering from mood disorders. Antidepressant Drugs All three major classes of antidepressant drugs work by “turning up the volume” on messages transmitted over certain brain pathways, especially those using norepinephrine and serotonin (Holmes, 2001). Tri- cyclic compounds such as Tofranil and Elavil reduce the neuron’s reabsorption of neurotransmitters after they have been released in the synapse between brain cells—a process called reuptake. A second group includes the famous anti- CONNECTION CHAPTER 3 depressant Prozac (ﬂuoxetine). These drugs are known as SSRIs (selective sero- Reuptake is a process by which neuro- tonin reuptake inhibitors) because they selectively focus on preventing the transmitters are taken intact from the reuptake of serotonin. As a result, SSRIs keep serotonin available in the synapse and cycled back into the terminal synapse longer by preventing its inactivation and removal. For many people, buttons of the axon. Reuptake, therefore, this prolonged serotonin effect dramatically lifts depressed moods (Hirschfeld, “tones down” the message being sent from one neuron to another. 1999; Kramer, 1993). The third group of antidepressant drugs are monoamine oxidase (MAO) inhibitors, which limit the activity of the enzyme MAO, a chemical that breaks down norepinephrine in the synapse. When MAO is inhibited, more norepinephrine is available to carry neural messages across the synapse. The possibility of suicide is a special concern when considering antidepressant therapy. It usually takes a few weeks for antidepressants to have an effect—a long time to wait if the patient has suicidal tendencies, which are common in depressed patients. This delayed effect may account for the ﬁnd- ings of a new study that shows an alarming increase in suicides in the month after patients begin taking antidepressants (Jick et al., 2004). Even more worrisome, according to some critics, is the possibility that the drugs themselves may sometimes contribute to suicidal thoughts by making depression worse before it gets better (Bower, 2004). While we wait for more research on this important issue, the U.S. Food and Drug Administration currently requires makers of antidepressant medications to warn physicians that patients taking these medications need close monitoring for suicidal tendencies. Controversy over SSRIs In his book Listening to Prozac, psychiatrist and Prozac advocate Peter Kramer (1993) encourages the use of the drug to deal not only with depression but also with general feelings of social unease and fear of rejec- tion. Such claims have brought heated replies from therapists who fear that drugs may merely mask the psychological problems that people need to face and resolve. Some worry that the wide use of antidepressants may produce changes in the personality structure of a huge segment of our population— changes that could bring unanticipated social consequences (Breggin & Breg- gin, 1994; Sleek, 1994). In fact, more prescriptions are being written for antidepressants than there are people who are clinically depressed (Coyne, 2001). The problem seems to be especially acute on college and university campuses, where increasing numbers of students are taking antidepressants (Young, 2003). At present, no one knows what the potential dangers might be of altering the brain chemistry of large numbers of people over long periods. Mood Stabilizers A simple chemical, lithium (in the form of lithium carbonate) has proved highly effective as a mood stabilizer in the treatment of bipolar disorder (Schou, 1997). Lithium is not just an antidepressant, however. It affects both ends of the emotional spectrum, dampening swings of mood that would otherwise range from uncontrollable periods of hyperexcitement to the ■ Antidepressant drugs Medicines lethargy and despair of depression. But lithium, unfortunately, has a serious that affect depression, usually by their effect on drawback: In high concentrations, it is toxic. Physicians have learned that safe the serotonin and/or norepinephrine pathways therapy requires that small doses be given to build up therapeutic concentra- in the brain. ■ Lithium carbonate A simple tions in the blood over a period of a week or two. Then, as a precaution, patients chemical compound that is highly effective in must have periodic blood analyses to ensure that lithium concentrations dampening the extreme mood swings of have not risen to dangerous levels. In a welcome development, researchers have bipolar disorder.

HOW IS THE BIOMEDICAL APPROACH USED TO TREAT PSYCHOLOGICAL DISORDERS? 551 found a promising alternative to lithium for the treatment of bipolar disorder (Azar, 1994; Walden et al., 1998). Divalproex sodium (brand name: Depakote), originally developed to treat epilepsy, seems to be more effective than lithium for most patients, and with fewer dangerous side effects (Bowden et al., 2000). Antianxiety Drugs To reduce stress and suppress anxiety associated with everyday hassles, untold millions of Americans take antianxiety drugs. Many psychologists believe, however, that these drugs—like the antidepressants— are too often prescribed for problems that people should face, rather than mask with chemicals. Nevertheless, antianxiety compounds can be useful in helping people deal with specific situations, such as anxiety prior to surgery or an airplane flight. The most commonly prescribed classes of antianxiety compounds are barbiturates and benzodiazepines. Barbiturates act as central nervous system depressants, so they have a relaxing effect. But barbiturates can be dangerous if taken in excess or in combination with alcohol. By contrast, the benzodiazepines, such as Valium and Xanax, work by increasing the activity of the neurotrans- CONNECTION CHAPTER 3 mitter GABA, thereby decreasing activity in brain regions more specifically GABA is the major inhibitory neurotrans- involved in feelings of anxiety. The benzodiazepines are sometimes called mitter in the brain. “minor tranquilizers.” Here are some cautions to bear in mind about the antianxiety drugs (Hecht, 1986): ❚ In general, the antianxiety drugs work by sedating the user; if used over long periods, these drugs can be physically and psychologically addicting (Holmes, 2001; Schatzberg, 1991). ❚ These medicines should not be taken to relieve anxieties that are part of the ordinary stresses of everyday life. ❚ When used for extreme anxiety, these drugs should not normally be taken for more than a few days at a time. If used longer than this, their dosage should be gradually reduced by a physician. Abrupt cessation after prolonged use can lead to withdrawal symptoms, such as convulsions, tremors, and abdominal and muscle cramps. ❚ Because the antianxiety drugs depress the central nervous system, they can impair one’s ability to drive, operate machinery, or perform other tasks that require alertness (such as studying or taking exams). ❚ In combination with alcohol (also a central nervous system depressant) or with sleeping pills, antianxiety drugs can lead to unconsciousness and even death. Finally, we should mention that some antidepressant drugs have also been found useful for reducing the symptoms of certain anxiety disorders, such as panic disorders, agoraphobia, and obsessive–compulsive disorder. (A modern psychiatrist might well have prescribed antidepressants for Freud’s obsessive patient.) Because these problems may arise from low levels of serotonin, they ■ Antianxiety drugs A category of may also respond well to drugs like Prozac that specifically affect serotonin drugs that includes the barbiturates and benzodiazepines, drugs that diminish feelings function. of anxiety. Stimulants Ranging from caffeine to nicotine to amphetamines to cocaine— ■ Stimulants Drugs that normally increase activity level by encouraging com- any drug that produces excitement or hyperactivity falls into the category of munication among neurons in the brain. stimulants. We have noted that stimulants find some use in the treatment Stimulants, however, have been found of narcolepsy. They also have an accepted niche in treating attention-deficit/ to suppress activity level in persons with hyperactivity disorder (ADHD). While it may seem strange to prescribe stim- attention-deficit/hyperactivity disorder. ulants (a common one is Ritalin) for hyperactive children, studies comparing ■ Attention-deficit/hyperactivity disorder (ADHD) A common problem stimulant therapy with behavior therapy and with placebos have shown a clear in children who have difficulty controlling their role for stimulants (American Academy of Pediatrics, 2001; Henker & Whalen, behavior and focusing their attention. 1989; Poling et al., 1991; Welsh et al., 1993). Although the exact mechanism is

552 CHAPTER 13 ❚ THERAPIES FOR PSYCHOLOGICAL DISORDERS unknown, stimulants may work in hyperactive children by increasing the availability of dopamine, glutamate, and/or serotonin in their brains (Barkley, 1998; Gainetdinov et al., 1999; Wu, 1998). As you can imagine, the use of stimulants to treat ADHD has generated controversy (O’Connor, 2001). Some objections, of course, stem from ignorance of the well-established calming effect these drugs have in children with this condition. Other worries have more substance. For some, the drug will interfere with normal sleep patterns. Additionally, there is evidence that stimulant therapy can slow the growth of children (NIMH, 2004). There are also legitimate concerns that a potential for abuse exists in the temptation to see every child’s behavior problem as a symptom of ADHD (Angold et al., 2000; Mar- shall, 2000; Smith, 2002). Critics also suggest that the prescription of stimulants to children might encourage later drug abuse (Daw, 2001). Evaluating the Drug Therapies The drug therapies have caused a revolution in the treatment of severe mental disorders, starting in the 1950s, when virtu- ally the only treatments available were talk therapies, hospitalization, restraints, “shock treatment,” and lobotomies. Of course, none of the drugs discovered so far can “cure” any mental disorder. Yet in many cases they can alter the brain’s chemistry to suppress symptoms. But is all the enthusiasm warranted? According to neuroscientist Elliot Valenstein, a close look behind the scenes of drug therapy raises important questions (Rolnick, 1998; Valenstein, 1998). Valenstein believes that much of the faith in drug therapy for mental disorders rests on hype. He credits the wide acceptance of drug therapy to the huge investment drug companies have made in marketing their products. Particularly distressing are concerns raised recently about the willingness of physicians to prescribe drugs for children— even though the safety and effectiveness of many drugs have not been established in young people (K. Brown, 2003a). Few question that drugs are the proper ﬁrst line of treatment for certain conditions, such as bipolar disorder and schizophrenia. In other cases, however, the apparent advantages of drug therapy are quick results and low cost. Yet some research raises doubts about simplistic time-and-money assumptions. Studies show, for example, that treating depression, anxiety disorders, and eating disorders with cognitive–behavioral therapy—alone or in combination with drugs—may be both more effective and economical in the long run than rely- ing on drugs alone (Barlow, 1996; Clay, 2000; Hollon, 1996).

Other Medical Therapies for Psychological Disorder Describing a modern-day counterpart to Phineas Gage, the headline in the Los CONNECTION CHAPTER 3 Angeles Times read, “Bullet in the Brain Cures Man’s Mental Problem” (Febru- Phineas Gage survived—with a changed ary 23, 1988). The article revealed that a 19-year-old man suffering from severe personality—after a steel rod was blasted obsessive–compulsive disorder had shot a .22 caliber bullet through the front through his frontal lobe. of his brain in a suicide attempt. Remarkably, he survived, his pathological symptoms were gone, and his intellectual capacity was not affected. We don’t recommend this form of therapy, but the case illustrates the potential effects of physical intervention in the brain. Accordingly, we will look brieﬂy at two medical alternatives to drug therapy that were conceived to alter the brain’s structure and function: psychosurgery and direct stimulation of the brain. Psychosurgery With scalpels in place of bullets, surgeons have long aspired to treat mental disorders by severing connections between parts of the brain ■ Psychosurgery The general term or by removing small sections of brain. In modern times, psychosurgery, the for surgical intervention in the brain to treat general term for such procedures, is usually considered a method of last resort. psychological disorders.

HOW IS THE BIOMEDICAL APPROACH USED TO TREAT PSYCHOLOGICAL DISORDERS? 553 Nevertheless, psychosurgery has a long history, dating back at least to medieval times, when surgeons might open the skull to remove “the stone of folly” from an unfortunate madman. (There is, of course, no such “stone”— and there was no anesthetic except alcohol for these procedures.) In modern times, the best-known form of psychosurgery involved the now- abandoned prefrontal lobotomy. This operation, developed by Portuguese psychiatrist Egas Moñiz,2 severed certain nerve fibers connecting the frontal lobes with deep brain structures, especially those of the thalamus and hypo- thalamus—much as happened by accident to Phineas Gage, whom we discussed in Chapter 3. The original candidates for Moñiz’s scalpel were agitated schizophrenic patients and patients who were compulsive and anxiety-ridden. The effects of this rather crude operation were often a dramatic reduction in agitation and anxiety. On the other hand, the operation permanently destroyed basic aspects of the patients’ personalities. Frequently, they emerged from the procedure with loss of interest in their personal well-being and their sur- roundings. Further, a lobotomy usually produced an inability to plan ahead, an indifference to the opinions of others, childlike actions, and the intellectual and emotional flatness of a person without a coherent sense of self. Not surprisingly, when the new drug therapies promised to control psychotic symptoms with less risk of permanent loss, the era of lobotomy came to a close in the 1950s (Valenstein, 1980). Psychosurgery is still occasionally done, but it is now much more limited to precise and proven procedures for very specific brain disorders. In the “split- brain” operation, for example, severing the fibers of the corpus callosum can reduce life-threatening seizures in certain cases of epilepsy, with relatively few side effects. Psychosurgery is also done on portions of the brain involved in pain perception in cases of otherwise intractable pain. Today, however, no DSM-IV diagnoses are routinely treated with psychosurgery. Brain-Stimulation Therapies Electrical stimulation of the brain in the form known as electroconvulsive therapy (ECT) is still widely used, especially in patients who have not responded to drug treatment for depression. ECT induces a convulsion by applying an electric current (75 to 100 volts) to a ● A sedated patient about to receive ECT. patient’s temples briefly—from one-tenth to a full second. The convulsion Electroconvulsive therapy involves a weak electrical current to a patient’s temples, usually runs its course in less than a minute. Patients are prepared for this causing a convulsion. Some psychiatrists traumatic intervention by sedating them with a short-acting barbiturate and a have found ECT successful in alleviating muscle relaxant. This renders them unconscious and minimizes violent, uncon- symptoms of severe depression, but most trolled physical spasms during the seizure (Abrams, 1992; Malitz & Sackheim, therapists regard it as a treatment of last 1984). Within half an hour the patient awakens but has no memory of the resort. seizure or of the events preparatory to treatment. Does it work? Crude as this treatment may seem—sending an electric current through the skull and brain—studies have shown ECT to be a useful tool in treating depression, especially in patients with suicidal tendencies that demand an intervention that works more rapidly than medication or psychotherapy (Glass, 2001; Holden, 2003; Hollon et al., 2002; Sackheim et al., ■ Electroconvulsive therapy (ECT) 2000). Typically, the symptoms of depression are reduced in a three- or four- A treatment used primarily for depression and involving the application of an electric current day course of treatment, in contrast with the one- to two-week period required to the head, producing a generalized seizure. for drug therapy to be effective. Speed can be a major concern in depression, Sometimes called “shock treatment.” where suicide is always a possibility.

2In an ironic footnote to the history of psychosurgery, Moñiz was shot by one of his disgruntled patients, who apparently was not paciﬁed as much as Moñiz had expected. This fact, however, did not prevent Moñiz from being awarded the Nobel Prize for medicine in 1949.

554 CHAPTER 13 ❚ THERAPIES FOR PSYCHOLOGICAL DISORDERS Some critics fear that ECT might be abused to silence dissent or punish patients who are uncooperative (Holmes, 2001). Other worries about ECT stem from the fact that its effects are not well understood. To date no definitive theory explains why inducing a mild convulsion should alleviate disordered symptoms. Most worrisome, perhaps, are the memory deficits sometimes caused by electroconvulsive therapy (Breggin, 1979, 1991). Proponents claim, on the other hand, that patients generally recover full memory functions within months of the treatment (Calev et al., 1991). In the face of such concerns, the National Institute of Mental Health (1985) investigated the use of ECT and gave it a cau- tious endorsement for treating a narrow range of disorders, especially severe depression. Then, in 1990, the American Psychiatric Association also pro- claimed ECT to be a valid treatment option. To minimize even short-term side effects, however, ECT is usually administered “unilaterally”—and only to the CONNECTION CHAPTER 3 right temple, in order to reduce the possibility of speech impairment (Scovern Speech is controlled by the left hemi- & Kilmann, 1980). sphere in most people. A promising new therapeutic tool for stimulating the brain with magnetic fields may offer all the benefits of ECT without the unwanted side effects of memory loss. Still in the experimental stages, transcranial magnetic stimulation (TMS) involves directing high-powered magnetic stimulation to specific parts of the brain. Studies indicate that TMS may be useful for treating not only depression but also schizophrenia and bipolar disorder (George, 2003; George et al., 1999; Helmuth, 2001b; Travis, 2000b; Wassermann & Lisanby, 2001). Because most applications of TMS therapy do not require the induction of a seizure, researchers hope also that it offers a safer alternative to ECT.

Hospitalization and the Alternatives We have seen that mental hospitals were originally conceived as places of refuge—”asylums”—where disturbed people could escape the pressures of normal living. In fact, they often worked very well (Maher & Maher, 1985). But by the 20th century these hospitals had become overcrowded and, at best, little more than warehouses for the disturbed with nowhere else to go. Rarely were people of means committed to mental hospitals; instead, they were given private care, including individual psychotherapy (Doyle, 2002a). By contrast, in the large public mental hospitals, a feeble form of “group therapy” was often done with a whole ward—perhaps 50 patients—at a time. But too many patients and too few therapists meant that little, if any, real therapy occurred. The drugs that so profoundly altered treatment in mental hospitals did not appear until the 1950s, so prior to that time institutionalized patients were often controlled by straitjackets, locked rooms, and, sometimes, lobotomies. It’s too bad that Maxwell Jones didn’t come to the rescue a half-century earlier, with his frontal attack on the mental hospital system.

The Therapeutic Community In 1953—at about the time antipsychotic drugs were introduced—psychiatrist Maxwell Jones proposed replacing traditional hospital “treatment” for mental disorders with a therapeutic community ■ Transcranial magnetic stimu- designed to bring meaning to patients lives. He envisioned the daily hospital lation (TMS) A treatment that involves routine itself structured as a therapy that would help patients learn to cope magnetic stimulation of speciﬁc regions of with the world outside. With these goals in mind, he abolished the dormitory the brain. Unlike ECT, TMS does not produce accommodations that had been typical of mental hospitals and gave patients a seizure. ■ Therapeutic community Jones’s more private living quarters. He required that they make decisions about meals term for a program of treating mental disorder and daily activities. Then, as they were able to take more responsibilities, by making the institutional environment patients assumed the tasks of everyday living, including laundry, housekeeping, supportive and humane for patients.

HOW IS THE BIOMEDICAL APPROACH USED TO TREAT PSYCHOLOGICAL DISORDERS? 555 and maintenance. Further, Jones involved them in helping to plan their own treatment, which included not only group psychotherapy but occupational therapy and recreational therapy as well (Jones, 1953). Eventually, variations on the therapeutic community concept were adopted across the United States, Canada, Britain, and Europe—sometimes more on paper than in reality, as we saw in Rosenhan’s “pseudopatient” study. But the changes did not come cheaply. The newer approach obviously required more staff and more costly facilities. The high costs led to a search for still another alternative, which came in the form of community-based treatment—which began to look more and more attractive with the increasing availability of drug therapies. Deinstitutionalization and Community Mental Health For mental health professionals of all stripes, the goal of deinstitutionalization was to remove patients from mental hospitals and return them to their communities for treatment in a more familiar and supportive environment. The concept of deinstitutionalization also gained popularity with politicians, who saw large sums of money being poured into mental hospitals (ﬁlled, inciden- tally, with nonvoting patients). Thus, by the 1970s, a consensus formed among politicians and the mental health community that the major locus of treatment should shift from mental hospitals back to the community. There both psychological and drug therapies would be dispensed from outpatient clinics, and recovering patients could live with their families, in foster homes, or in group homes. This vision became known as the community mental health movement. Unfortunately, the reality did not match the vision (Doyle, 2002a; Torrey, 1996, 1997). Community mental health clinics—the centerpieces of the community mental health movement—rarely received the full funding they needed. Chronic patients were released from mental hospitals, but they often returned to communities that could offer them few therapeutic resources and to families ill-equipped to cope with them ● Deinstitutionalization put mental patients (Arnhoff, 1975; Smith et al., 1993). Then, as patients returned back in the community—but often without to the community and needed care, they entered psychiatric wards at local gen- adequate resources for continued treatment. eral hospitals—rather than mental hospitals. As a result, hospital care has continued to consume most funding for mental health in the United States. Currently, mental patients account for about 25% of all hospital days (Kiesler, 1993). Some disturbed individuals, who would have been hospitalized in an earlier time, have now all but disappeared from view within their communities. An estimated 150,000 persons, especially those with chronic schizophrenia, have ended up homeless, with no network of support (Torrey, 1997). Although estimates vary widely, up to 52% of homeless men and 71% of homeless women in the United States probably suffer from psychological disorders, and many of them are former mental hospital patients (Fischer & Breakey, 1991; Lamb, 1998). Many also have problems with alcohol or other drugs (Drake et ■ Deinstitutionalization The policy of removing patients, whenever possible, from al., 1991). Under these conditions, they survive by shuttling from agency to mental hospitals. agency. With no one to monitor their behavior, they usually stop taking their ■ Community mental health medication, and so their condition deteriorates until they require a period of movement An effort to deinstitutionalize rehospitalization. mental patients and to provide therapy from Despite the dismal picture we have painted, community treatment has not outpatient clinics. Proponents of community mental health envisioned that recovering proved altogether unsuccessful. After a review of ten studies in which mental patients could live with their families, in foster patients were randomly assigned to hospital treatment or to various community- homes, or in group homes. based programs, Kiesler (1982a) reported that patients more often improved in

556 CHAPTER 13 ❚ THERAPIES FOR PSYCHOLOGICAL DISORDERS the community treatment programs. Further, those given community-based treatment were less likely to be hospitalized at a later date. When community health programs have adequate resources, they can be highly effective (McGuire, 2000).

PSYCHOLOGY IN YOUR LIFE: WHAT SORT OF THERAPY WOULD YOU RECOMMEND? Now that we have looked at both the psychological and biomedical therapies, consider the following situation. A friend tells you about some personal problems he or she is having and requests your help in finding a therapist. Because you are studying psychology, your friend reasons, you might know what kind of treatment would be best. How do you respond? First, you can lend a friendly ear, using the techniques of active listening, acceptance, and exploration of alternatives, which we discussed earlier in the chapter. In fact, this may be all that your troubled friend needs. But if your friend wants to see a therapist or if the situation looks in any way like one that requires professional assistance, you can use your knowledge of mental disorders and therapies to help your friend decide what sort of therapist might be most appropriate. To take some of the burden off your shoul- ders, both of you should understand that any competent therapist will always refer the client elsewhere if the required therapy lies outside the therapist’s specialty. A Therapy Checklist Here, then, are some questions you will want to consider before you recommend a particular type of therapist: ❚ Is medical treatment needed? While you should not try to make a diagnosis, you should encourage your friend to see a psychiatrist for medical treatment if you suspect that the problem involves psychosis, mania, or bipolar disorder. Medical evaluation is also indicated if you suspect narcolepsy, sleep apnea, epilepsy, Alzheimer’s disease, or other problems recognized to have a biological basis. If your suspicion is confirmed, the psychiatrist may employ a combination of drug therapy and psychotherapy. ❚ Is there a specific behavior problem? For example, does your friend want to eliminate a fear of spiders or a fear of flying? Is the problem a rebellious child? A sexual problem? Is she or he depressed—but not psychotic? If so, behavior therapy or cognitive–behavioral therapy with a counseling or clinical psychologist is probably the best bet. (Most psychiatrists and other medical practitioners are not trained in these procedures.) You can call the prospective therapist’s office and ask for information on specific areas of training and specialization. ❚ Would group therapy be helpful? Many people find valuable help and support in a group setting, where they can learn not only from the therapist but also from other group members. Groups can be especially effective in dealing with shyness, lack of assertiveness, and addictions, and with complex problems of interpersonal relationships. (As a bonus, group therapy is often less expensive than individual therapy.) Professionals with training in several disciplines, including psychology, psychiatry, and social work, run therapy groups. Again, your best bet is a therapist who has had special training in this method and about whom you have heard good things from former clients. ❚ Is the problem one of stress, confusion, or choice? Most troubled people don’t fall neatly into one of the categories that we have discussed in the previous

HOW IS THE BIOMEDICAL APPROACH USED TO TREAT PSYCHOLOGICAL DISORDERS? 557 paragraphs. More typically, they need help sorting through the chaos of their lives, ﬁnding a pattern, and developing a plan to cope. This is the territory of the insight therapies. Some Cautions We now know enough about human biology, behavior, and mental processes to know some treatments to avoid. Here are some particularly important examples: ❚ Drug therapies to avoid: The minor tranquilizers are too frequently prescribed for patients leading chronically stressful lives (Alford & Bishop, 1991). As we have said, because of their addicting and sedating effects, these drugs should only be taken for short periods—if at all. Similarly, some physicians ignore the dangers of sleep-inducing medications for their patients who suffer from insomnia. Although these drugs have legitimate uses, many such prescriptions carry the possibility of drug depen- dence and of interfering with the person’s ability to alter the conditions that may have caused the original problem. ❚ Advice and interpretations to avoid: Although psychodynamic therapy can be helpful, patients should also be cautioned that some such therapists may give ill-advised counsel in problems of anger management. Traditionally, Freudians have believed that individuals who are prone to angry or violent outbursts harbor deep-seated aggression that needs to be vented. But, as we have seen, research shows that trying to empty one’s aggressions through aggressive behavior, such as shouting or punching a pillow, may actually increase the likelihood of later aggressive behavior. With these cautions in mind, then, your friend can contact several therapists to see which has the skills and the manner that offer the best ﬁt for her or his problem and personality.

CHECK YOUR UNDERSTANDING

1. RECALL: Which class of drugs blocks dopamine receptors in the c. prefrontal lobotomy brain? d. the “split-brain” operation a. antipsychotics e. antipsychotics b. antidepressants 4. The community mental health movement followed a c. antianxiety drugs RECALL: deliberate plan of ______mental patients. d. stimulants a. hospitalizing e. depressants b. deinstitutionalizing 2. RECALL: A controversial treatment for attention-deﬁcit/hyperactivity c. administering insight therapy to disorder involves d. removing stressful events in the lives of a. antipsychotics. e. lobotomizing b. antidepressants. 5. Drug therapies, c. antianxiety drugs. UNDERSTANDING THE CORE CONCEPT: psychosurgery, and ECT all are methods of treating mental disorder d. stimulants. a. by changing the chemistry of the body. e. depressants. b. by removing stress in the patient’s life. 3. RECALL: Which of the following medical treatments for mental dis- c. that always succeed. order has now been largely abandoned as ineffective and dangerous? d. that have no scientiﬁc basis. a. electroconvulsive therapy e. by directly altering the function of the brain.

b. lithium

e b c d a 5. 5. 4. 3. 2. 1. ANSWERS:

558 CHAPTER 13 ❚ THERAPIES FOR PSYCHOLOGICAL DISORDERS THERAPIES: THE STATE OF THE ART Prompted initially by questions about the effectiveness of therapy and later by a shift to managed health care, the mental health professions have begun to identify specific psychological and biomedical treatments that are effective for specific disorders. The disorders for which real help now exists include depression, phobias and other anxiety disorders, certain schizophrenias, ADHD, and autism. We can expect to see more and more such treatments identified, especially in the realm of drug therapies. On the negative side, some drug therapies are overprescribed, as physicians and patients seek quick fixes for mental problems. The reality is that most DSM-IV disorders have no easy cures. For these, time is required for counseling or psychotherapy that may be necessary to sort through problems and examine alternative solutions.

USING PSYCHOLOGY TO LEARN PSYCHOLOGY

How Is Education Like Therapy? onsider the ways in which psychotherapy is like ing a more active part in the learning process. Inci- Cyour classroom experiences: dentally, an active approach to the course will also ❚ Most therapists, like most teachers, are profession- help you stand out from the crowd in the teacher’s als with special training in what they do. mind, which could be helpful if you later need a teacher recommendation for college. ❚ Most patients/clients are like students in that they Now consider a parallel between education and are seeking professional help to change their lives group therapy. In group therapy, patients learn from in some way. each other, as well as from the therapist. Much the ❚ Much of what happens in therapy and in the class- same can occur in your psychology course, if you con- room involves learning: new ideas, new behaviors, sider other students as learning resources. As we new insights, new connections. noted earlier in this book, the most successful students It may help you learn psychology (and other sub- often spend part of their study time sharing informa- jects, as well) to think of teaching and learning in tion in groups. therapeutic terms. As we have seen, therapy seems to One other tip for learning psychology we can bor- work best when therapist and client have a good row from the success of behavior therapies: the impor- working relationship and when the client believes tance of changing behavior, not just thinking. It is easy in the value of the experience—and the same is to “intellectualize” a fact or an idea passively when almost certainly true for the student–teacher rela- you read about it or hear about it in class. But you are tionship. You can take the initiative in establishing a likely to ﬁnd that the idea has little impact on you (“I personal-but-professional relationship with your psy- know I read about it, but I can’t remember it!”) if chology teacher by doing the following two things: you don’t use it. The remedy is to do something with (1) asking questions or otherwise participating in your new knowledge: Tell someone about it, come up class (at appropriate times and without dominating, with illustrations from your own experience, or try of course) and (2) seeking your instructor’s help on acting in a different way. For example, after reading points you don’t understand or on course-related top- about active listening in this chapter, try it the next ics you would like to pursue in more detail (doing so time you talk to a friend. Educators sometimes speak during regular office hours). The result will be learn- of this as “active learning.” And it works! ing more about psychology, because you will be tak-

USING PSYCHOLOGY TO LEARN PSYCHOLOGY 559 CHAPTER SUMMARY

● WHAT IS THERAPY? Operant techniques include contingency management, which People seek therapy for a variety of problems, including DSM-IV especially involves positive reinforcement and extinction strate- disorders and problems of everyday living. Treatment comes in gies. And, on a larger scale, behavior therapy may be used to many forms, both psychological and biomedical, but most involve treat or manage groups in the form of a token economy. Partici- diagnosing the problem, finding the source of the problem, mak- pant modeling, based on observational learning therapy, may ing a prognosis, and carrying out treatment. A variety of profes- make use of both classical and operant principles, involving the sionals work under this model. In earlier times, treatments for use of models and social-skills training to help individuals prac- those with mental problems were usually harsh and dehumaniz- tice and gain confidence about their abilities. ing, often based on the assumption of demon possession. Only In recent years a synthesis of cognitive and behavior thera- recently have people with emotional problems been treated as pies has emerged, combining the techniques of insight therapy individuals with “illnesses,” which has led to more humane with methods based on observational learning theory. Rational– treatment. emotive behavior therapy helps clients recognize that their irra- Currently in the United States, there are two main tional beliefs about themselves interfere with life and helps them approaches to therapy: the psychological and the biomedical learn how to change those thought patterns. therapies. Psychological therapies include insight therapy and The effectiveness of therapy was challenged in the 1950s behavior therapy—each of which, in turn, come in several forms. by Eysenck. Since that time, however, research has shown that Other cultures often have different ways of understanding and psychotherapy can be effective for a variety of psychological treating mental disorders, often making use of the family and problems. Often it is more effective than drug therapy. As the community. In the United States there is a trend toward increas- research on mental disorders becomes more refined, we are ing use of paraprofessionals as mental health care providers, learning to match specific psychotherapies to specific disorders. and the literature generally supports their effectiveness. Most people do not get psychological help from professionals. Rather, they get help from teachers, friends, clergy, ● Therapy for psychological disorders takes a variety of and others in their community who seem sympathetic. Friends forms, but all involve some relationship focused on improv- can often help through active listening, acceptance, and explo- ing a person’s mental, behavioral, or social functioning. ration of alternatives, but serious problems require professional assistance. ● HOW DO PSYCHOLOGISTS TREAT ● PSYCHOLOGICAL DISORDERS? Psychologists employ two main forms of treatment: the insight therapies (focused on developing understanding of The first of the insight therapies, psychoanalysis grew out of the problem) and the behavior therapies (focused on Sigmund Freud’s theory of personality. Using such techniques as changing behavior through conditioning). free association and dream interpretation, its goal is to bring repressed material out of the unconscious, where it can be ● interpreted and neutralized, particularly in the analysis of transfer- HOW IS THE BIOMEDICAL APPROACH USED ence. Neo-Freudians typically emphasize the patient’s current TO TREAT PSYCHOLOGICAL DISORDERS? social situation, interpersonal relationships, and self-concept. Biomedical therapies concentrate on changing the physiological Among other insight therapies, humanistic therapy focuses aspects of mental illness. Drug therapy includes antipsychotic, on individuals becoming more fully self-actualized. In one form, antidepressant, mood stabilizing, antianxiety, and stimulant medi- client-centered therapists strive to be nondirective in helping cines. Most affect the function of neurotransmitters, but the their clients establish a positive self-image. precise mode of action is not known for any of them. Neverthe- Another form of insight therapy, cognitive therapy concen- less, such drugs have caused a revolution in the medical treat- trates on changing negative or irrational thought patterns about ment of mental disorder, such as schizophrenia, depression, oneself and one’s social relationships. The client must learn more bipolar disorder, anxiety disorders, and ADHD. Critics, however, constructive thought patterns in reference to a problem and apply warn of their abuse, particularly in treating the ordinary stress of the new technique to other situations. This has been particularly daily living. effective for depression. Psychosurgery has lost much of its popularity in recent years Group therapy can take many approaches. Self-help support because of its radical, irreversible side effects. Electroconvulsive groups, such as AA, serve millions, even though they are not therapy, however, is still widely used—primarily with depressed usually run by professional therapists. Family therapy and cou- patients—although it remains controversial. A new and promising ples therapy usually concentrate on situational difficulties and alternative involves transcranial magnetic stimulation of specific interpersonal dynamics as a total system in need of improve- brain areas. Meanwhile, hospitalization has been a mainstay of ment, rather than on internal motives. medical treatment, although the trend is away from mental The behavior therapies apply the principles of learning— hospitals to community-based treatment. The policy of deinstitu- especially operant and classical conditioning—to problem behav- tionalization was based on the best intentions, but many mental iors. Among the classical conditioning techniques, systematic patients have been turned back into their communities with few desensitization is commonly employed to treat fears. Aversion resources and little treatment. When the resources are available, therapy may also be used for eliminating unwanted responses. however, community treatment is often successful.

560 CHAPTER 13 ❚ THERAPIES FOR PSYCHOLOGICAL DISORDERS If someone asks your advice on finding a therapist, you can however, some specific therapies and therapeutic techniques refer him or her to any competent mental health professional. to avoid. You should avoid trying to make a diagnosis or attempting ther- ● Biomedical therapies seek to treat psychological disor- apy for mental disorders, but you may use your knowledge of ders by changing the brain’s chemistry with drugs, its cir- psychology to steer the person toward a medical specialist, a cuitry with surgery, or its patterns of activity with pulses of behavior therapist, group therapy, or some other psychological electricity or powerful magnetic fields. treatment that you believe might be appropriate. There are,

REVIEW TEST

For each of the following items, choose the single correct or if she wants to try. In behavioral therapy, this technique is best answer. The answer key appears at the end of the test. known as 1. Despite the differences between various types of therapy, a. clinical ecology. all therapeutic strategies are designed to b. counterconditioning. a. make the client feel better about him- or herself. c. behavioral rehearsal. b. help the individual fit better into his or her society. d. participant modeling. c. change the individual’s functioning in some way. e. systematic desensitization. d. educate the person without interfering with his or her 6. A patient finds herself feeling personally fond of her thera- usual patterns of behavior. pist, who reminds her of her father. This is an example of e. utilize medication in arriving at a final therapy. the psychoanalytic process known as 2. While professionals with somewhat different training and a. resistance. orientations can provide similar forms of therapy in which b. reaction formation. all of the following groups are trained practitioners, only c. regression. ______on the list below are qualified to prescribe medica- d. negative transference. tions for the treatment of mental or behavioral disorders. e. transference. a. neuropharmacologists 7. Which of the following problems might best be corrected b. psychiatric social workers through rational–emotive behavior therapy (REBT)? c. psychologists a. An addicted smoker wants to quit. d. psychotherapists b. A young man has an extreme fear of heights. e. psychiatrists c. An average-weight woman diets constantly, believing 3. Because a central goal of the therapist is to guide a patient that she must be thin in order to have anyone love her. toward understanding the connections between past origins d. A patient complains of continual “voices” in his head and present symptoms, psychodynamic therapy is a form of telling him that people are trying to harm him. ______therapy. e. An elderly male has memory problems. a. insight 8. In recent years, psychotherapy research has found b. cognitive a. drugs to be more effective than cognitive–behavioral c. behavior therapy. d. rational–emotive behavior b. insight therapy to be more effective than behavioral e. group therapy for most disorders. 4. Lola has an irrational fear of speaking in front of others. c. most mental problems to have their roots in uncon- With the support of her instructor and her entire psychology scious motives or emotions. class, Lola confronts her fear by standing alone in front of d. specific therapies that are highly effective for specific her classmates and talking about her phobia. This strategy disorders. of placing the individual in the dreaded situation is called e. that nearly all individuals eventually “get better” with or a. exposure therapy. without therapy. b. catharsis. 9. Valium, a drug with a high “abuse potential,” is classified as c. insight therapy. an ______medication. d. social-learning therapy. a. antianxiety e. group. b. antidepressant 5. To teach his young daughter not to be afraid to swim, a c. antipsychotic father tells her to “Watch me!” as he wades into the surf, d. antihistamine then rolls with the waves, and finally invites her to join him e. stimulant

REVIEW TEST 561 10. Which of the following statements about electroconvulsive c. ECT is known to work by increasing the stimulation of a therapy (ECT) is true? particular neurotransmitter in the brain. a. Proper ECT applies a very strong electric current directly d. ECT works best with manic patients. to a patient’s brain without the need for sedatives or e. ECT is a sure way to “cure” resistant depression. anesthetic medication.

b. Some studies have found ECT to be effective in the

b a d c b d a a e c 10. 10. 9. 8. 7. 6. 5. 4. 3. 2.

treatment of severe depression. 1. ANSWERS:

KEY TERMS

Therapy (p. 524) Reflection of feeling (p. 534) Token economy (p. 541) Antianxiety drugs (p. 552) Psychological Cognitive therapy (p. 536) Participant modeling (p. 542) Stimulants (p. 552) therapies (p. 529) Group therapy (p. 536) Cognitive–behavioral Attention-deficit/hyperactivity disorder (ADHD) (p. 552) Biomedical therapies (p. 529) Self-help support therapy (p. 542) (p. 553) Insight therapies (p. 531) groups (p. 537) Rational–emotive behavior Psychosurgery Electroconvulsive therapy Talk therapies (p. 531) Behavior modification (p. 538) therapy (REBT) (p. 543) (ECT) (p. 554) (p. 532) (p. 538) Active listener (p. 548) Psychoanalysis Behavior therapy Transcranial magnetic (p. 549) Analysis of Systematic Psychopharmacology stimulation (TMS) (p. 555) transference (p. 533) desensitization (p. 539) Antipsychotic drugs (p. 550) Therapeutic Neo-Freudian psychodynamic Exposure therapy (p. 540) Tardive dyskinesia (p. 550) community (p. 555) therapies (p. 533) Aversion therapy (p. 540) Antidepressant drugs (p. 551) Deinstitutionalization (p. 556) Humanistic therapies (p. 534) Contingency Lithium carbonate (p. 551) Community mental health Client-centered management (p. 541) movement (p. 556) therapy (p. 534)

AP* REVIEW: VOCABULARY

Match each of the following vocabulary terms to its deﬁnition. d. This is the category of drugs that includes benzodiazepines and barbiturates. 1. Psychoanalysis 6. Psychopharmacology 2. Client-centered therapy 7. REBT e. This type of therapy is based on Albert Ellis’s form of 3. Cognitive therapy 8. Antianxiety drugs cognitive therapy. 4. Behavior therapy 9. Stimulant f. The goal of this therapy is to release conﬂicts and 5. Aversion therapy memories from the unconscious. a. This therapy is essentially based on operant and g. This therapy pairs an attractive stimulus with an classical conditioning. aversive one in order to condition revulsion. b. This therapy involves the prescribed use of drugs to h. Chemical compounds that increase activity level by help treat symptoms of mental illness so that individ- encouraging communication among neurons in the uals are more receptive to talk therapies. brain. c. This therapy emphasizes an individual’s tendency for i. This therapy focuses on rational thinking as the key to healthy psychological growth. treating mental disorders.

562 CHAPTER 13 ❚ THERAPIES FOR PSYCHOLOGICAL DISORDERS AP* REVIEW: ESSAY

Use your knowledge of the chapter concepts to answer the would treat a patient with bipolar disorder. Be sure that your following essay question. response addresses diagnosis, methodology, and differences between the two therapies. Compare and contrast the ways in which a psychopharmacolo- gist and a rational–emotive behavior therapy (REBT) therapist

OUR RECOMMENDED BOOKS AND VIDEOS

BOOKS VIDEOS Beam, A. (2001). Gracefully insane: The rise and fall of America’s Analyze This. (1999, color, 103 min.). Directed by Harold Ramis; premier mental hospital. New York: PublicAffairs. This is a history starring Robert DeNiro, Billy Crystal, Lisa Kudrow. This is a comedy of McLean Hospital outside Boston, Massachusetts, the mental about an arrogant mob boss, overwhelmed by emotional reactions hospital equivalent of a luxury hotel, which over the years offered to his “work,” who insists on the help of a psychotherapist reluctant “spa” treatments and retreat for wealthier patients and celebrities, to hear his tale of criminal woe. A funny satire, with insights into the including author Sylvia Plath, poet Anne Sexton, musicians Ray ethical challenges of therapy, this film is better than its lame 2002 Charles and James Taylor, and Susanna Kaysen of the memoir sequel, Analyze That. (Rating R) and movie Girl, Interrupted, about her two-year stay in McLean. Good Will Hunting. (1997, color, 126 min.). Directed by Gus Van Sant; Berger, L., & Vuckovic, A. (1995). Under observation: Life inside the starring Matt Damon, Robin Williams, Ben Affleck. A troubled working- McLean Psychiatric Hospital. New York: Penguin Books. This vivid class youth—and mathematical genius—is helped by a renowned portrayal of life in psychiatric institutions is illustrated with case MIT professor and an offbeat psychologist (Williams in his Oscar- histories and the personal stories of patients who emerge not as winning role) to confront his painful past and discipline his talents. characters but as real people, disturbingly familiar and similar to (Rating R) ourselves. Spellbound. (1945, black-and-white, 111 min.). Directed by Alfred Hitch- cock; starring Gregory Peck, Ingrid Bergman, Leo G. Carroll. The classic Davidson, J., & Dreher, H. (2003). The anxiety book: Developing mystery concerns an amnesic who may or may not be a murderer, strength in the face of fear. New York: Riverhead Books/Penguin. helped by the psychoanalyst with whom he has fallen in love. The This guide to identifying the level and sources of your own anxiety surreal dream sequences were designed by artist Salvador Dali. assesses its impact on your life and discusses using cognitive (No Rating) techniques, physical exercise, and professional resources for treatment. What About Bob? (1991, color, 99 min.). Directed by Frank Oz; starring Bill Murray, Richard Dreyfuss, Julie Hagerty. A professional psychi- Hesley, J. W., & Hesley, J. G. (2001). Rent two films and let’s talk in the atric patient proves the undoing of a pompous psychiatrist, pursued morning: Using popular movies in psychotherapy, 2nd edition. by the needy, neurotic man to his family summer vacation—where New York: John Wiley & Sons. The authors offer a wonderful guide the patient proceeds to charm everyone, clarifying the psychiatrist’s to using therapeutic “videowork” to get more out of feature films own inabilities as a father and husband. The film is a sometimes whose plots and messages provide information and imagery of disturbing comedy about the artificial barriers blocking the unique psychological disorders and treatment. therapist–client relationship. (Rating PG)

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